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BACKWATER PREVENTION PROGRAM <br />� INVOICE COST BREAKDOWN <br />Please use this Invoice Cost Breakdown as a lei �plate for invoices submittod as part of the Backwater <br />Prevention Device rebate program. Either this form or your own invoice form with the foilowing Iine items can <br />be� staH'to tlent fy hlow c sts elig bte tor therBalckwate �Pre eMio� Devi ce' Rebalte were alcce ed Ie allowing <br />Only labor and materials direcGy related to the insta/lation and function of a backwater prevention <br />device are eligible for Ciry rebate and therefore should be included on the upper half of this form. <br />Additional costs may be added to bottom of the (orm. �^ � J <br />5'r�^ � �L�� <br />Business Name:.�yY�Pri �nf� �l}ii� a✓_�(L�P-- License Number. _�j�r? '`� <br />- „ ,. <br />Business Mailing Address: ollGc-tc l.Gc' Lf'� `� "`"' � Cit Siate Zip <br />Y <br />Phone:��'-�/�`�''Si� Emait:C'�lY�l(c�n�wn�a�l�i�r�n.� s'��Cp.� . .�C C•v7Y1 <br />Revised 9/03/2014 <br />