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BACKWATER PREVEIVTION PROGRAM <br /> � INVOICE COST BREAKDOWN <br /> Please use this Invoice Cost Breakdown as a template for invoices submilted as part of the Backwater <br /> Prevention Devi�e rebate program. Either this form or your own invoice form with the following line items can <br /> be submitled. This allows you to invoice your client according to your existing billing template while allowing <br /> city staff to identify how costs eligible for the Backwater Prevention Device Rebate were accrued. <br /> Only labor and materials directly related to the installation and function of a backwafer prevention <br /> device are eligi6le for Ciry rebate and therefore shoufd 6e included on the uppe�half of this form. <br /> Addifional costs may be added ro bottom of the form. ,� <br /> t5�'��i�" /,� <br /> Business Name:,�'IPn�� r� ���1}�-i<-c�_• i�P License Number: (�S�S`Z� _ <br /> Business Mailing Address: r�G:z�c L.F�/"I�l'l tl1 t� T Il'�!"�',���A U��'���.3 <br /> City State Zip <br /> � Phone:��'.�/C> ^�Yl�al_ Email:(�� )�t�v�n«zn�>J}1�iU �nrj� S'r��C' cr2'./: C'c� <br /> Catc o Descri tion Units Quanti Rate Total <br /> Administration Administralion I management Hours <br /> Labor CCTV Inspeclion Hours � _ <br /> BUJV Install Hours <br /> Pipe replacement Hours <br /> Surtace reslora�ion Hours <br /> Sita cleanup Hours <br /> Downspouls I drainage imp. Hours <br /> Materials �ackwater valve Per Unit 4' � <br /> Grinder pump Per Unit <br /> Side sewer pipe(up to 8 feeq Feel _���' <br /> Impohed Backfill Yards <br /> Surface Restoration Malerials Lump <br /> (top soil,grass seed,concrele,etc. sum � O �C7. <br /> Cover(irrigalion box or load Bearing Per Unit —� �� <br /> caver <br /> Rentals Speci(y equipment Hou� <br /> C�� -� - <br /> Fees Disposal ices�y item Yards _�a� <br /> Dr.livery fces if nol covcred by IaUor _ <br /> Eli ibleTotal � <br /> Othcr Cosls Costs not associated�vith OWD,and <br /> nol eliqible for rebate detaii below _ <br /> hD �' ,�� Lv.huc/i✓- <br /> '_ v�"?--"`= <br /> ti <br /> IneligibleTotal u"�� � 6 S <br /> Total $ g — <br /> Revised 9/03/2014 <br />