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�BACKWATER PR�VE�ITION PROGRAM <br />INVOICE C�ST BREAKDOWN <br />Please use this Invoice Cosl Breakdo�•:: � as a template for invoices submitted as part of the Backwater <br />Prevention Device rebate program. Either lhis form or your own invoice fortn with lhe follnwing line items can <br />be submitted. This allows you to invoice your client according to your existing billing template while allowing <br />city staf( to identify how c�sts eligible for the Backwater Prevention Device Rebate were accrued. <br />Only Isbor and materials directly r�lared to the installa�ion and function of a backwater prevention <br />device arc eliglble for City rebaM and thene/are should be included on tlre upper hall o/ fhls fo►m. <br />Additinnal costs may be added to botrom ol the form. <br />6usiness Name: ��m �! �� (.�_ C Lice:ise Number: /�iM��V ��6//YP <br />BusinessMailingAddress: ��c�� V��7�'�i-VaI���Z [� `�U"� � %-�'� � ���� <br />Phone: ��2r—y89- o iz 3 <br />Othcr Costs <br />Administr-alion / manaBement <br />CCN Inspecdon <br />BVW Install <br />Pipe replacement <br />Surface restoration <br />Site cleanup _ <br />Oownspouts / drainape imp. _ <br />Dackwatervatve <br />Grinder pump <br />Side sewer p�pe (up l0 9 feet) _ <br />Imported Backfill <br />Surface Restoralion Matenals <br />(top soil arass seed concrete, elc.) <br />Cover (irtigation box or load bearing <br />cover) <br />Speciry equipment <br />D!sposal (ees by ilem _ ____ <br />Delivery fces if not covered by labor <br />Costs nol associaknf wilh DWD, and <br />nol elioi6lc for rebate (delail hetow) <br />Revised 9/03/2014 <br />_ (v� !'J/I LC.0 <br />Units Ouonti Ratc <br />Hnurs <br />Hours ' / � G <br />Hours / 2 <br />Hows <br />liours � <br />Hou;s <br />Hours <br />Per Un�t <br />Per Unit <br />Feet <br />Yards <br />sumr � � <br />%Z� <br />r � '7 5' <br />� b � Z'Z-t � <br />$ _ 2�-1� . 3 0 <br />