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_ <br /> BACKWATER PREVENTION PROGRAM <br /> INVOICE COST BREAKDOWN <br /> Please use this Invoice Cost Breakdown as a template for invoices submitted as part of the Backwater <br /> Prevention Device rebate program. Either this fortn or your own invoice form with the following line items can <br /> be submitted. This allows you to invoice your client aocording to your existing billing templata while allowing <br /> city staH to identify how costs eligible for tha Backwater Prevention Device Rebate were accrued. <br /> Only labor and materials directly related to the installation and function of a backwaterprevenHon <br /> device are eligible for City re6ate and therefore shoufd be included on the upper half of thts form. <br /> Additional costs may 6e added to bottom of the lorm. �7 � S UQ,�r^0�( <br /> 5�'�"�C•�-�'' �,r,�y� <br /> �j �Z` ,(��, .S;nIB License Number: { <br /> Business Name:. SE;,r—� <br /> Business Mailing Address: o�/!%��v L.F.21��41 iJu�-' E�1L��'� Ii�A ��a(�_ <br /> �i�y State Zip <br /> Phone:i�7(n'.�1c?���'� Email:y,�,^rv'�irii7ri'—^��aC][� �r'���'2"I-CYSYYI <br /> Cate o Deseri tion Unifs Ouanti Rate Total <br /> AdminislreHon Administrationlmanagement Hours <br /> Labor CCN Inspectlon Hours <br /> gVW Instell HouB � <br /> Pipe repla�ement Hours <br /> Surface restoration Hours <br /> Site cleanup Hours <br /> DownsDouts/drainage imp. ,�ours <br /> Materiais Backwaler valve Per Unit <br /> Grinder pump Per Unit <br /> Side sewer ipe(up to 8 feet Feet �� �' <br /> Imported Bac�ll Yards <br /> Surface Restoration Meterials Lump � O _ <br /> to soil rass seed,concrete etc. sum <br /> Cover(irrigalion box or load hearing Per Unit <br /> cover <br /> Rentals Specify eq ipment Hour <br /> Fees Disposal tees by item Yards <br /> Delivery fees if not covered b labor . <br /> EII Ihle Total $ ' <br /> Cusls nol associated wilh BWD,and L <br /> Other Costs not eli ible for rebate detail below r r "�.. r <br /> �Y. <br /> Ineligible Total � $ <br /> Total $ <br /> r� �'v� �Z � <br /> Revised 9iO3/2014 <br />