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i <br /> BACKWAl'ER PREVFNTtiON PROGRAM ; <br /> INVOICE COST g�FcEAKDOWN ; <br /> Please use ihis Invoice Cost Dreakdown as a template for invoicQs submitted as part of the Backwater ; <br /> Prevention Device rebate program. Either this form or your own invoice form with the following line items can ! <br /> be submitted. Tliis allows you to invoice your clienl according to your existing billing template while ailowing j <br /> city staH to identify how costs eligible for the Backwater Prevention Device Rebate were accnied. ' <br /> i <br /> Only la6or and materials directly related to the Installation and function ofa 6ackwate�prevention <br /> devJce are e►igi6fe Ior City rebate and therefore should be include�+on the upper half of this form. <br /> Additionaf costs may be added 10 boftom o/fhe form. ; <br /> �.�� � <br /> ��,,S�c�° �/l V <br /> Business Name:�����_ � � ��iyr License Numher. __('j��,j�•1 <br /> 4 11IT, �ar_ - <br /> Business Mailing Address: b�/i,'G�r. (.G��,�.GL_ r,jfi'IZ',7� 1.L���._3 <br /> City Slate Zip <br /> Phone:k��"_��_ [maii:,(i��)�� � ics����[.l[]ll-_5-idP�ry�2"!: C'c�Yl� <br /> rCate o Descr�tion ___. Units �Quantit R�te Total �. <br /> Administration Administration/managemeni Hours _ <br /> Labor CCTV Inspection __ Hours _ _ _ __��__ _ <br /> BWV Install Hours __ _� <br /> Pipe replacement Hours � ; <br /> Surface restoralion Hours a( ,�(�- <br /> � Site cleanup _ Hnurs _ _ <br /> Downspoutsldrainac�cimp. Hours ' <br /> Matorials Bar.kv�ater valva Per Unil -� �� _�� - � � _�-� <br /> Grinder pump Per Unit � <br /> 5ide sev�er pipe(up to 8 feel) Feet� I i �� aG��� —� <br /> Imported Baskfill Yards _ � _______ _ <br /> Sudace Reslorolion Materiais Lump <br /> __ to soil qrass seeA r.oncrete elc. sum 7 ' , <br /> �--L --- — �-- ---�—_ .__��(� <br /> Cover(irrigation box or load bearing Pcr Unit <br /> cover ----- — �a - �---- <br /> Rentals Specify equipment Hour _ _ <br /> --- -�cL}'Li�=fC�[x�--- -- --- ---+�-- --_ - �-• �. <br /> �- ---- ----- � --— -- �----.. <br /> Foes Disposnl fees by itr.m _ Yards _` __�'� _� _ � <br /> - _ < <br /> Delivery fees if not coverecf by I�bor _ __ _ <br /> EII Ible Tolal ' �' � <br /> Othcr Costs Cos�s nol associated�vith BWD,and <br /> nol olic ible(or mbale(detail belovi�_ � _ <br /> — - - - -- - - - � <br /> Ineligible Total � � <br /> Total _� — $ � �� <br /> Revised 9/03/201A � <br />