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�,��K��1��R PR���N�'6�� ��0��� <br />��' lid�/09�� C�S� ������O�V�R <br />Please use this Invoice Cost Breakdown as a templelo tor invoices submitt,;d as part ot 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 lo Invoice your client according to your existing billing template while allowing <br />city staff to identiiy how costs eligible for lhe Backwater Prevention Device Rebate were accrued. <br />Only /aborartd maferiafs direcHy relaMd ta fhe instaflation and /uncNon ol a backHater preventiort <br />devlee are eli�ibfe ier City rEbat2 and fherefoie shoufd be included an the apper half of th/s Ponn. <br />Additlonal costs may be added to boftom oi the Iortn. <br />Business Name: l�- " � a �'lc / C , License Number. � I u�:�'� )% �f t1 <br />. _ . _ _ ._— . a . . -. <br />Business Mailing Address: <br />id <br />Phone: �45—`�riy"U/Z�� Email: ��''/���-���/oii'�H//� .��!�i�`'��'7�,�jnL-C�"%l <br />Revised 9/03/2014 <br />