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0 1-- BACKWATER PREVENTION PROGRAM <br />0;:7T INVOICE COST BREAKDOWN <br />Please use this Invoice Cost Breakdown as a template for invoices submitted as part of 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 to invoice your client according to your existing billing template while allowing <br />city staff to identify haw costs eligible for the Backwater Prevention Device Rebate were accrued <br />Only labor and materials directly related to the installation and function of a backwater prevention <br />device are eligible for City rebate and therefore should be included on the upper half of this form. <br />Additional costs may be added to bottom of the form. <br />Business Name; Qg e j License Number: <br />Business Mailing Address: <br />Prone: UJ►}-b <br />Cate o <br />Deseri tion <br />Units <br />Duanti <br />Rate <br />Total <br />Administration <br />Administration I management <br />Hours <br />Labor <br />CCTV Inspection <br />Hauls <br />BWV Install <br />Hours <br />Pirie replacement <br />Hours <br />Surface restoration <br />Hours <br />Site cleanup <br />Hours <br />Downspouts 1 drainage Imp. <br />Hours <br />Materials <br />Backwater valve <br />Per Unit <br />'i <br />CR <br />Grinder pump <br />Per Unil <br />Side sewer pipe (up to 8 feet) <br />Feet <br />r <br />Imported Backfill <br />Yards <br />_ <br />_ <br />Surface Restoration Moterials <br />(top soil, grass seed concrete, etc.)_.sum <br />Lump <br />3� <br />Cover (irrigation box or load hearing <br />cover <br />Per Unit <br />e3 <br />a <br />Rentals <br />Specify equipment <br />Hour <br />Fees <br />Disposal fees by ilem <br />Yards <br />Delive fees if not eoverei by labor. <br />Eligible Total <br />$ <br />Other Costs <br />Costs of associated with DWD, and <br />not eligible for rebate_ detail below <br />0(c <br />l) ! Cat <br />tw tv nro w <br />t" <br />3 <br />Ineligible Total <br />$ <br />Total <br />$ <br />Revised 9/03/2014 <br />jPit () <br />