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BACKWATER PREVENTION PROGRAM <br />INVOICE COST BREAKDOWN <br />Plcase use this Invoice Cost Breakdown as a t>�nplate for invoices submiried as part of the Backwater <br />Prevention Device rebate program. Either ti��is form or your own invoice form with the following line items can <br />be suhmitled. This allows you to invoice your -lient according to your existing billing lemplate while allowing <br />city slaH to identify how costs eligible For the Backwaler Prevention Device Rebate were accrued. <br />Only /abo► and materials directly relat�td fo the insfallation and lunction of a 6ackwater prevention <br />device are eligible !or Cify re6ate and theiefore should be included on fhe upper half of this (orm. <br />Addifional costs may he added to bottom of the lorm. <br />Business Name: �(L.P�+"YI� l�`-i,C _ License Number: __L` / P/��pQ�___ <br />� / �/fsj�7i l�ii �Yi2__��{'� z r,r�% (tib? _�'1 _d a <br />F3usines� ivi�iling Address� ____. - <br />'7 /,� �jity• Sr�t�a�te7 Z' <br />Phone:_"1 � 5 —J�9 —d/Z �_ Email:_�'}fi ��Jh� 1�/�� �� oZJ��L �� <br />Revised 9103I2014 <br />