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� BACKWATER PREVEIVTION PROGRAM <br />� INVOICE COST �REAKDOWN <br />Please use this Invoice Cos, Breakdown as a tempiate tor invoicos submitted as part of 1he Backwater <br />Prevention Device rebate program. Either ihis form or your own invoice form wi�h the follo�ving line items can <br />be submitted. This allows you to invoice your client according to your exisling billing lemplate �vhile allowing <br />city staff to identify how costs elic�ible (or the Backwater Prevention Device Rebate were accrued. <br />Only labor and materials directiy related to the lnstallation and funcfinn of a b er half o�hls formn <br />device are eligible tor Ciry rebate and there(ore should be included on the upp <br />Addifronal costs may bo added fo botfom of the lonn. <br />5���� L(ti <br />Business Name:.���r��, t-� ._ ' L���P - License Nurnber. � .�?� �� _ ^ _ — <br />Business Mailinc� Address: r.i(L�-{c% ���� ��� �!�'�-' —� ��y� ��� - St e Zip <br />Phone:,�.�,��C�,'� �maiC� �)�y}��!'iCi✓�,rx,� c. tLl(J.�aci�b��u%G—�s� <br />Reviscd 9/03/201•1 <br />