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BACK�iIAiEi2 PREVEN�"ION P120G12AM <br />INifOIGE CC1ST BfREAKDOWN <br />Please use this Invoice Cost Breakdown as a template for invoices submitted as pa.t of the Backwater <br />Prevention Device rebate program. Either lhis form or your own invoice form with the following line items can <br />bey s affltoe dentify hlow costs elig ble for therBalckwate �Preven�ion Dev e' Robalte we e alccr ed'Ie allowing <br />Only labor and materials directfy reJated ro the installation and function of a backwaterprevention <br />device are eliyible for Ciry rebate and iherefore should be included on fhe upperhalf of this form. <br />Addrtional costs may be added to botfom of the (orm. <br />5l�tiC i r'�'� .—L%�', �?�U <br />L, e 1_icense Number. — <br />Business Name;��i•zl1�'�— ' <br />Business Mailing Address: i��% �-G�rf �� ����e Z�P �— <br />Y <br />Phone:.��a'��iC�--:�'')�:� Email:�i�aJTY'rY�l�-�_L•iL7�-�rlP�a��Y'(: !%19 <br />Revised 9/03/2014 <br />