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$011P` <br /> �`� BACKWATER PREVENTION PROGRAM <br /> O INVOICE T BREAKDOWN <br /> �•�' COST <br /> Please use this Invoice Cost Breakdown as a template for invoices submitted as part of the Backwater <br /> Prevention Device rebate program. Either this form or your own invoice form with the following line items can <br /> be submitted.This allows you to invoice your client according to your existing billing template while allowing <br /> city staff to identify how costs eligible for the Backwater Prevention Device Rebate were accrued. <br /> Only labor and materials directly related to the installation and function of a backwater prevention <br /> device are eligible for City rebate and therefore should be included on the upper half of this form. <br /> Additional costs may be added to bottom of the form. <br /> Business Name: 411- f!Lfrz IJ! L� License Number: •4 f1v`i 07/ p <br /> Business Mailing Address: 8 f t( Vi itte 6vzie.vc- c&- EZ <br /> Cit <br /> State Zip <br /> Phone:4� S"t"© Z O rn k irL ILC- (-'-r7 In tL •C +�' 'gn <br /> t � Email: ter.-�JI� i2q <br /> Category Description Units Quantity Rate Total <br /> Administration Administration/management Hours <br /> Labor CCTV Inspection Hours / ?C}© <br /> BWV Install Hours / /f3 O <br /> Pipe replacement Hours / `3 S <br /> Surface restoration Hours / 4/ 5`0 <br /> Site cleanup Hours <br /> Downspouts/drainage imp. Hours <br /> Materials Backwater valve Per Unit 1 2 5Z) <br /> Grinder pump Per Unit <br /> Side sewer pipe(up to 8 feet) Feet <br /> Imported Backfill Yards <br /> Surface Restoration Materials Lump /�� <br /> (top soil,grass seed,concrete,etc.) sum <br /> Cover(irrigation box or load bearing Per Unit ` b o <br /> cover) <br /> Rentals Specify equipment Hour <br /> Fees Disposal fees by item Yards suh <br /> Delivery fees if not covered by labor <br /> �J <br /> 7 X2 7- <br /> Eligible Total ( j $ <br /> Other Costs Costs not associated with BWD,and <br /> not eligible for rebate(detail below) <br /> 00 <br /> Ineligible Total $ <br /> Total $ <br /> V <br /> Revised 9/03/2014 <br />