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BACKWATER PREVENTION PROGRAM <br /> INVOICE COST BREAKDOWN <br /> Please use this invoice Cost Breakdown as a template for invoices submitted as part ot the Backwaler <br /> Prevention Device rebate program. Eilher Ihis form or your own invoice form with the following iine items can <br /> be submi!ted. This allows you to invoice your client according to your existing billing template while allowing <br /> cily staif to identify how cosis eiigible for the Backv�ater Prevention Device Reb2te n�ere accrued. <br /> Only labor and materials direcUy related to the installation and function of a backwater pievention <br /> device are eligible for Ciry rebate and therefore should be included on the [lpper half of this form. <br /> Additiorta!costs may be added!o bofrom of[he fonn. <br /> 5�-��� u-� v <br /> Business Name:��(_��t¢12��.t'_ <-'��SiC`P License Number: __�JS��.:L <br /> Business Mailing Address: oZ�c L!"t c '1 �C_• _/�(f��L—GL�� ����1�,3— <br /> Cily State Zip <br /> Phone .�7(��1Q_"�a�Q�'�l EmaiC_Cif�Llfjk � � . �i��� S'ciESN1.c.2' .(' C'cSYI'I <br /> Category DescriPtion Units Quantit Rate Total <br /> Administration Administration/management Hours _ _ <br /> Labo� CCTV Ins eclion Hours <br /> p----- — �--��— . � <br /> � BUW Instail Houts _ ____ <br /> Pipe replacement Hours <br /> Surfacc restoration _ Hours � p�(_ <br /> Sile cleanup Houts <br /> Downspouts!drainape imp. Hours <br /> Ma[erials �ack�vater valve Per Unil �� , - ��__ <br /> Grindcr pump Per Unit <br /> � Side sewer pipe(up to 8 feet) Feet `< <� _ae�a �_ <br /> Irnported Backfill Yards ___ _ __ <br /> Sudace Restoralion Materiuls Lump <br /> __{top sotl,grass seed, concrete, elc.) sum � �_ __ <br /> Covcr(i�rigalion box or load bearir.g Per Unil <br /> �o���� � i a a_— <br /> Rentals Specify equipmenl Hour_ _ <br /> --—'�l _Y!���'� -- a�t'7--- --�� — <br /> — - ------ -- — ------- - -- <br /> Fces Di�posal(eer.hy ilem _, Yards �� <br /> -- ----- - '— ---- -- - -��._,. _ <br /> Delwery fees if nol covr.rr.c1 by labor _ _ __ <br /> ------- - -_- - - -...-- --- �- -- --- -. ..- -- - --- - - - <br /> Eli ible Total � $ ' <br /> Other Costs Costs not associated with BWD, and <br /> not eligible for rebate(detail beio�t)__ __ _ ____ <br /> - ---- -- — �— —tfiV1 <br /> _ -- _�uv V _3_a33 -- <br /> '1— <br /> Ineligible Total � <br /> Total � ���F p�_ 3 � . <br /> �It,a �C�'"`5all <br /> Revised 9/03/2014 �� "��I{ <br />