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BACKWATER PREVEIVTION PROGRAM <br />INVOICE COST BFtEAKDOWN <br />Please use this Invoice Cost Breakdown as a template for invoices submitted as part ot the Backwater <br />Prevention Device rebate program. Either this form or yuur own invoice forrn wilh the following line items can <br />be submitled. This allows you to invoice your client according to your existing billing template while allowing <br />city staff to identify how costs eligible for the Backv�aler Prevention Device Rebale were accrued. <br />Only labor and materials direcHy related to fhe installation and funetion ofa backwater prevenfion <br />device are eligible for Ciry rebate and therefore should be rncluded on the upper half of this form. <br />Ac�difional costs may be added to 6ottom of the form. <br />5�,��y � �C,C; <br />RusinessName:Nd11P_^_�n�:�1� ��.���%e LicenseNumber.__QS,��_. <br />Bu;iness Mailing Address: <br />State <br />Phone:��'�/�� Email:(�liY%�cz�, '�. �nrl S���I,r;,�'� C'cSY)'1 <br />IZ�I �i /�`t <br />Ra�,sed sio3i2o�a <br />