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BACKWATER PREVEIVTION PROGRAM <br />INVOICE COST BREAKDOWN <br />Please use this Invoice Cost Breakdown as a template for invoices submi;ted as part of ihe Backwa;er <br />Prevention Device rebate program. Either this form or your ovm invoice form viith ihe following line items r,an <br />be submitted. This al!ov�s you to invoice your client according to your existing billing template while allo�ving <br />cily staff to idenhfy ho�v costs eli�ible for the Backvn. ter Prevention Device Rebate were accrued. <br />Cnly labor end materials direct7y related to the installatlon nnd function of a 6ackwater prevention <br />device are eligible (or Ciry rebate and Uierefore should be inr.luded on the upper half of this form. <br />Additional cosfs may bo added to boh'om of the /o�m. <br />�c�'r; �,(..L: <br />Business Name:Ay�(al.<zl�_ �. ' L��,`S�C�PSLicense Number: � � r �� ___ _ <br />a�i�c �.U� X/ � �-j�'� �-.-1L��1-- �� �'�G,3— <br />Business Mailing Address _ � _ c 't . _ _�_ _ _ <br />City State Zip <br />Phone:,z��v_�1�>--�lt,'"�` EmaiLii�fl�i'�iiv�ntall�.� ��1 S'.IrrC,�'!: �s�79 <br />� Category _ DescriPtion _ �_ Units �uanti Rato I Tatal _ <br />Admmistranon Administration I management Hours _ � <br />� -- <br />�Labor CC7V Inspection _ Ilours L�_ �� <br />` -- - BVW Install Hours � \_ _ - _ _ � -- <br />Materials <br />R�ntals <br />Feos _ <br />Eliqible Total <br />Othcr Losts <br />Ineliaible Total <br />Sur�ace restoration <br />Sile cleinup <br />Down=_pouts � drainage imp <br />packv�alcr valvc <br />Hours <br />Per Unit <br />� sewer pipe (up l0 8 tee[ _I ree� <br />orted Backiill Yaids <br />face Rr.storalion blalcr��ls Lump <br />� so_I, grass seed, concrete, etc. sum <br />�er (irtiga;ion box or IoaA hearing Per ll <br />er __ — Hour <br />!cify equipmeM _ <br />�✓lL��_���--- — <br />pOsal (res by ilem __ _ _ Y���` <br />iveiy fer.s i( nut_covercA by lal�or_ '_ <br />Cosls nol associated �vith E3WD, and <br />ncl eligible for rebate (detail hclow _ __ _ <br />Reviscd 9iO3��Z014 <br />t <br />� a_ <br />---�_—_— �s <br />