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BACKWATER PREVENTION PROGRAM <br /> •7 INVOICE COST BREAKDOWN <br /> , <br /> Please use this Invoice Cost Breakdown as a templaie for invoices submitted as oart of the B�ckwater <br /> Prevention Device rebate program. Either this form or your own invoice form tivith the following line items can <br /> be submitted.This allows you lo invoice your client according to your exisling billi�g template�vhile ailowing <br /> city staf(to identify how costs eligible for the Backwater Prevention Device Rebate were accrued. <br /> Only labor and materials directty related to the lnstalfation and funcfion of a backwater pr�evention <br /> device are eligltrle for City rebate and therefore should be included on the upper half of thls form. <br /> Additional costs may be added fo boftom of the form. <br /> ���St'L+t��r L�.Ci <br /> Business Name;�n�fi�`r'��rry� License Number. _,Q�____ <br /> Business Mailing Address: o�4X-(c L.C[r�c I't aJ�-' Cit '�� Sta��� <br /> v <br /> Phone:�•�lU ._1L2� Email:�'j�u�ritan��/N�i�r.�L►t�e-b���'�=s� <br /> Catc o Deseri tion Units Quanti Rate Total <br /> Administralion AdminisUation!manayement Hours _ __�._ <br /> Labor CCNlnspec�ion Hours _ C� ,� <br /> BWV Install _ Hours <br /> Pipe replacemenl Hours _ <br /> Sudace restoralion Hours <br /> Sitecleanup Hours --— � <br /> Downspouls I drainape imp._ Hours � <br /> Materials Backwatervaive PerUni( ') �,5 <br /> Grindcr pump Per Unit <br /> Side sewer pipe(up l0 8 feel)__ Feet " �' � — <br /> hnported Backfdl _ Y:�rds _ — <br /> Surface Restoralion Matcrials L��mp � 3C7 <br /> (top soil,grass seed,concrete,etc.) sum _ _. — <br /> Cover(irrigalion box or Icnd bearing Por Unit �� <br /> cov� �---- �— — <br /> Rentals Specifyequipment Hour _ _ _ � <br /> f►'lik�A -7"lt:t��"-�2�_-- - —�J�C� ' <br /> Fecs — Disposal fees by i(em Vards -- _ � <br /> Delive fees if not covered by labor ___ ___.—�` <br /> Eli Ible Total � � � � <br /> Other�oscs Costs not associated wilh BWD,and <br /> nol eli i61e for rebale_delail beiow� — <br /> - - (� -- p� ---o � ; �- _ <br /> - -a-�-`-�- -� — <br /> - - ^ _��� �_ <br /> Ineliclible Total $ <br /> Total -----. U <br /> ��� <br /> � �� ��f S <br /> Revised 9/03/20i4 <br />