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BACKWATER �REVENTIUN PROGRAM <br />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 ihis form or your o�vn invoice form with the following line items can <br />be submitted. This allows you to invoice your client according to your existing billing tempiate while allowing <br />city staff to identify how costs eligible for the Backwater Prevenlion Device Rebate we;e accrued. <br />Only labor and maferials directly related to the installation and ftir,ction of a 6ackwaterprevention <br />device are eligiblc for City re6afe and therefore �houfd be included on the up��er half of this form. <br />Additional costs m�y be added to bottom of the Iorm. <br />Business Name: F�O f�uW�i7lna License Number: �lPO�L- PL G03GT <br />Business Ivtailing Address: S�/D7 7Isl' �v�,dl�—C'13 ` Ciry �� � 9� e�� Zip <br />Phone: �/„ZS- 3g7 -/�07 Email:_(�n P,�j�l(e�whyl?���" — <br />Revised 9/03/2014 <br />