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i <br /> BACXWATER PREVENTION PROGRAM � <br /> INVOICE COST BREAKDOWN <br /> Piease use tNis Invoice Cost Breakdown as a template for invoices submitted as part of the Backwater i <br /> Prevention Qevice rebate program. Either fhis form or your own invoice form with the Following line items can � <br /> be submitted. This allows you to Invoice your client according lo your existing billing tempiate tivhilo allowing i <br /> city staH to id�nti(y 15ow costs eligible for the Backwater Prevention Device Rebate were accrued. � <br /> Only labor and materlals directly rnlated to the installation and function of a backwater prevention j <br /> devlce aYe eligible for Ciry re6ate and therefore sliould be included on the upper haff of this form. <br /> Additional costs may be adde d to boltom o�fhe (orm. ! <br /> /�j� ���''''''""" 1 <br /> BusinessName:���(J�'�'1����CLicenseNuinber./��!�n�SS �� ; <br /> Business Mailing Address: ���� �3G��� S�•✓���1• � ��� �' �'�� _J���'� � <br /> / 7 / City Slate . Zip �, <br /> Phone:�0(�'�S ���I7 Email:1�ol�i,�rx_�'L�S•i; �� cF� �J " .([!/7 <br /> Cetegory_ Description _ UNts puantit� Rate Total ; <br /> Administretion Adminislration f inenepemeM Hours _ _ ______ <br /> Labor CClV inspection _ Nours 7 _ _ _ <br /> BWVlnstall Hours � ____ <br /> Pipe replacement _ Hours ���,� �Qp1__n ' <br /> Sudace restoratioa Hours , _ _ <br /> Site cleanup _ Hours � a _ _— __ , <br /> Dowrspouls 1 drainape imp. Hours <br /> Materlals Back�valer valve ___ �er Unihj y��_�Qtj aCC�,E-G ; <br /> - — Grinder pump Per Unil - --- _ - <br /> Side sewer pipe(up lo B(eel) _ Fcet _ _ _ i __ _ <br /> Imported�ackfill __ Yards _ ___ _ <br /> J � Sudace Re. r tion Materials Lutnp , r U�' �O <br /> - •--` _- -(to�soi qr. �• _ co�crete,etc. sum �5��- � --- �. <br /> Cov irriga ia� r load bearin� Per Unit r��i� �Q.���j <br /> cover �� - <br /> Rentals - - Specify equipment - _ _ H���r __ 1M�ug _��.L� _.o�Gf)�.� <br /> - - __._._ - - - - -- _-- <br /> Fer.s , Dispos�l fces by ilem - � -- Yards _ .�S - -�Q�_- _��!E� <br /> Delivery fees i(not r.ovr.red by I�bor __ __ _ _ S� a,�(v�_UU <br /> ------- -- ` ---- - -- -- - -- - X - S 8-��� <br /> Eli iblr Total � <br /> Other Costs CO�`�s°°�°`"0r,iatod with HWI),and ' <br /> nol eli�ible for rebalc(detuil belo� _,�_ ____ ___.. -_ - ____ <br /> — -- — <br /> --- -- ----O4 fU c �c. r' h1.w �... <br /> � --L-- -- -- --L - 4�''— --- --- -- <br /> ----- --- — - — - -- —— ---�.w—!��--_— <br /> --- ---------- - ---- --- --�'ll' I�„��..�� � <br /> Inoligible Total 7 � ; <br /> Total - - -- _-- § ------ <br /> -- i <br /> Revisod 9/03/2014 i <br />