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� <br /> BACKWATER PREVENTION PFI�GRAM � <br /> �' lNVOICE COST BREAKDOWN I <br /> Please use this Invoice Cost Breakdown as a templale for invoices submitted as part o(the Backwater I <br /> Prevention Device rebate program. Either this torm or your own invoice form with the following line items can ' <br /> be submitted. This allows you lo invoice your client acrording lo ycur existing billing templale while allowing I <br /> city staH to identify how costs eligible for the Backwaler Prevention Device Rebate were accrued. j <br /> I <br /> Only la6o►and materials d(re:tly related to the instal/ation and lunction ol a backwafer prevention i <br /> devfce are eligible lor City rebate and therelore should 6e included on fhe upper hal�01 this/orm. , <br /> Additional wsts may be added lo boMum o/fhe form. <br /> Business Name:�( �! L Lir.ense Number.���/�- o��P� � <br /> Business Mailing Address:�f'� U�.1'rµ✓��i�wl. � i.� ��r ���� ! <br /> ` ,p Ciry State Zip <br /> Phone: LC1'S- L1 O n?-UIZ�j Email: /9D4WIlM1I�(F2�1 LLL��1� C']n'Y4f I � <br /> i <br /> --- -- — - - ---- - -- - <br /> � <br /> Cate o Descri tion Units Quantit Rate Total __ ! <br /> 9 �--- - �- - - - � <br /> Adminislration Administration/management Hours ._. � <br /> Labor CCNlnspection Hours J '?jOC� _ � <br /> - — BWV Install- -- Hours � I 2 j _ <br /> - ---- <br /> -- - f <br /> Pipe replacement - Hours � __ 2_S—O . <br /> Surlace restoretion Hours _ , <br /> Silacleanup Hours /%�-�__ <br /> Oownspouts/drainage imp. Hours <br /> -- — --- — - <br /> Materlals Dackwater velve Per Unil / 2 O __ � <br /> Grinder pump Per Unil __ <br /> Side sewer pipa(up l0 8 fcet) Feet _ _ . _ _ ! <br /> Imported Backfdl Yerds <br /> `/ --� SurTaco Resloretion Materials - Lump / ��� ! <br /> '7,� � (top soil,grass seed,cancrete,etc. sum __ _ __ <br /> -- Cover(irrigation boz or load beariny Per Unil <br /> cover)_ . . . —._- - -� -- <br /> Rentais Specity equipmenl _ Hou� _ _ __ _ � <br /> -- . .._. -- -- --- — - � <br /> --- - ----� -- - — - 1 <br /> - — - i <br /> Fees Disposal lees by item Yards <br /> ---- - � <br /> -- - - — <br /> - -- __ � 3D- <br /> m�-T ------ - _ _ i <br /> Delivmy fces il nol covered by lahor_ � <br /> --- ---- - -- - - -- -. __— i <br /> — - — -- — <br /> ---- ��,- I <br /> Eli ible Total $ <br /> 01her Costs Cosls nol associaled wiUi BWD,and . <br /> not elyible for rebale detail below_ __ _ . __ _. - �?j Q <br /> -_ _ : _ _ _ - k--- -r�� 3 � ; <br /> i <br /> - --- _ --- — — $ �L �� , <br /> Ineli i61e Total i <br /> Tolal ---- � -- --- — $— -- - � <br /> i <br /> i <br /> Revised 9/032014 <br /> � <br /> ; <br />