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BACKWATER PREVENTION PROGRAM <br />INVOICE COST BREAKDOWM <br />Please use this Invoice Cost Breakdown as a template inr invoices submitted as paA of ihe Backwater <br />Prevenlion Device rebate program. Eith.:r !his form or your own invoice iorm with the following line Hems can <br />be submitted. This allows you to invoice your client according to your exisHng billing tempiate while allowing <br />city staff to identify how costs eligible for the Backwater Prevention Device Rebate were accrued. <br />Only labor and materiafs direcNy rclated to the insfallation and firnction ol a backx�ater prevention <br />device are efigible for City rebate and theretore should be included on ihe upper helf of thlu form. <br />Additional cosf,s may be added to bottom o/ th,� lorm. <br />Business Name: �r9-Pju�a� ��jr) �r i1- � License Number: ,�h9LJ%���Jl/P/� <br />Business Mailing Address: � I �/1�i1'iL✓z�l'�'�R l��` L`�� �(� _ <br />Phone: .L�2 1 '. Ei �-�/' O / �-'� <br />C�?J <br />Revised 9/03/2014 <br />