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BACKWATER PREVENTION PROGRAM <br /> INVOICE COST BREAKDOWN <br /> Please use this Invoice Cost Breakdown as a template for invoices submitted as part of ihe Backwater <br /> Prevention Device rebate program. Either this form or your own invoice form with the following line items can <br /> be submitted. 71tis allows you to invoice your client according lo your existing billing template while allowing <br /> city staH to identity how costs eligible for the Backwater Prevention Devfce Rebate were accrued. <br /> Only Jabor and materials direcUy related to the instaNatfon and funcSon of a 6ackwat¢r prevention <br /> device are eligible for Ciry rebate and therefore should be included on the upper half of this form. <br /> Addilional cosfs may be added to bottom of fhe Iorm. <br /> � ��,5�'c�-.�' �������yv <br /> Business Name:.��.���}yL�r_�1�_License Number.__l�'_..�?'�-��'1. <br /> Rusiness Mailing Address: oZGX� L.Gc(�1cVl f 1�-__.f�(f�� �� � <br /> City State Zip <br /> Phone:�',�f0 ^,'�'1S�'-� Email:�'iQ���c.�n,�-�!}h�r]n�l s�r�P��c� ('� <br /> Cate9ory Desc�tion Unitr Quanti Rate Tot�l <br /> Adminlslration AdminisValion I manapement Hours <br /> Labor CCTV Inspeclion __ _ Hours _� _ I <br /> BVN/Install Hours _ <br /> pipe replar.ement Hours <br /> Sudace resloration Hours � <br /> Sila cleanup fiours _ <br /> Downspouls/drainage imp. Hours _ .� l �O <br /> MaMrials Backwater valve Per Unit -� �_Iry�.�.r� _s�11"9— <br /> Grinder pump Per Unit <br /> Side sewer pipa u to 8(eet Feet _ �� �.loi! �i -� <br /> Imported Backfill Yards _ __.__ <br /> Surface Resloralion Materials Lump <br /> ro soi� grass seed, concr�etc)__ sum �� ___� 3 0 <br /> Cover(irrigation box or load bearing Por Unil <br /> cover �_._ _�a— <br /> --�— ---- --- --- -- ---- <br /> Rentals Sper.ify equipment Hour ______ <br /> _ __ rv��.,-►;�`�-r�.c 4=4.�e --- —1 —--:�� _ _. _-3ae�_ <br /> _ r <br /> Fees Diposnl fer.s by ilmn .--'-- Yards - - ---- .� �^� <br /> --- - 0�04�-— <br /> - — Dclivery ler.s if nol r.oveicA by Inbnr ---- - -- --- _— . <br /> ___.. . --- - ---..--- --- - $ -T <br /> EII ible Total a <br /> Othcr Cos4s Cosls not associatetl with RWD,and <br /> not eligibl�a for rebale{delail below_ _. <br /> ------ - --- --- - O�_ Fo ���s cc�n eVv./ — <br /> iv�l.�Uf7�J _ <br /> _ —_—_—____—_ '___ _'__ .�ANL �[w, <br /> -� -� �' .___ _'__.— �� _�„6tlll <br /> Ineligihle Total -----�- --- �-- --- - -� � � ? G/i) <br /> Total ---- - ---- --- -- ----- _�� _�sY <br /> Rvvised 9/03/2014 <br />