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BACKWATER PREVEfVTION PROGRAM <br /> � INVOICE COST BREAKDOWN <br /> Please use this Invoice Cost Breakdown as a tempiate for invoices submitted as part of the Backwater <br /> Prevention Device rebate program. Either this form or your own invoice form�vith ihe follo�ving line items can <br /> be submitted. This allows you to invoice your client according to your exisling bi!ling template while allowing <br /> city staft to identify ho�v cosls eligible for the Backwater Prevention Device Rebate were accrued. <br /> Only labor and materials directly related to the instailation and function of a backwater prevention <br /> device are elrgibfe for Ciry rebate and therefore should be included on the upper half of this form. <br /> Additional costs may 6e added to bottom of the form. <br /> c5'eccl'�',�' c•• �/ <br /> Business Name:.�IP(�(� �� 4��-���'�P License Number: (�J��� �"� <br /> Business fUailing Address: o��% �.!'[. c � '1,. l�-. r���r�'� «�� n���3 <br /> Cily State Zip <br /> � Phone:�.�'.�/c>•-,��'� EmaiL•Ci/Y�>nm�n�an �� ��f�A Si 'C�r,-r�'!: C`c�27'I <br /> Category Descri tion Units Quanti Rate Total <br /> Administrelion Adminislrationlmanagement Hours <br /> Labor CCTV Inspeclion Hours <br /> B�W Install Hours <br /> Pipe replacement Hours <br /> Surface restoration Hours � <br /> Sile cleanup Hours <br /> Downspoutsldrainageimp. Hours <br /> Materiais Backwaler valve Per Unit -{; '� •r,., -� <br /> t�. <br /> Grinder pump Per Unit J <br /> Side sewer pipe(up to 8 feet) Feet < « G" 7 <br /> ImpoAed 9ackfill Yards _ <br /> Surface Restoration Materials Lump <br /> to soil rass seed,concrete,etc. sum � c��_ <br /> Cover(irrigation box or load bearing Per Unil —'` <br /> �o�erl _ � <br /> Rontals Speci'ry equipment Hour <br /> �1C��— � - <br /> Fces Disposal fecs by ilr.m Yards _ <br /> a�a-�� <br /> Delivery fees if not covered by labor <br /> Eli ible Total � <br /> Othcr Costs Cosls nol associated with BWD,and <br /> not eli ible for rebale detail below __ <br /> lt f7i }p cr.ti c lu <br /> v ��Vr�utl <br /> t+�4 a� <br /> IneligibleTotal ��-t�i �$,�,L�.rr <br /> Total $ v <br /> Revised 9/03/2014 <br />