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BACKWATER PREVEfVTION PROGRAM � INVOICE COST BF�EAKDOWN Please use this Invoice Cost Breakdow� as a template for invoices submitted as part of the Backwalor Prevention Device rebate program. Either this form or your own invoice form with ihe following line ilems can be submilled. This allows you to invoice your client according to yow exisling billing iemplale while aliowing city staff to identify how cosls eligible for ihe Backwater Prevention Devi�e Rebale were accrued. Only labor and materials Jirectly related ta the installatron and function of a backwater prevention device are eligible foi Clfy rebate and therefore should be included ort the upper half of thls form. Additional cosfs may be added fo botfom ol the (orm. 5;�� C� BUsiness Nd�ne;�fij.(rt_!'_T�S�e Licenso Number: _�� Business Mailing Address: o�� LG�i�_.I.IV�-• f—f%L'L�t.i �s.�/-� �<� •3 _ City State Zip Phone:��_c�,"�,� Email _� s' 17n�/'�uU�� d-�-irl�r.:c3"l�?71 Administration Labor Rentals Surfacc resloration_ Silo cleanup Downspouts 1 drAina� Dar,kweler valve se��er�ipe {up to rted Backfill p sou, grass seea, concre wer (irrigalio � box or load vcr) _ �ecify equipment � Hours Houre --`-- Hours Hours _ Hours _ / Haurs �� h'ouB Pcr Unil ��-� Per Unil � Feel ��p Yartls � i_ump e, etc. sum —�-- -- —1-- bearing Per Unil — � Hour — - — --- � Fecs —�'- Dinpos�l fr.�� : by_Icm . _-_ ____ Cielivery ler.s d nol crneir.d 6y Libor _ Eli ible Total — — — - 1�1� — — Othcr Costs C�51s nol associalcd with E3WD, rmd nol ehjible lor rebatc (detail br.low) _ Ineligiblc Total Tolal _ ._ — -- - - - - - — -- � — Revised 9/03/2014 -- � _.___ �i�—r7x� S��d�/-h FG N'1� Mie-yl.� `2=`�=— — US'f a f /S' _ 5 8o2_8-a'-