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BACKWA�EFt PREVENTION PROGRAM <br /> � INVOICE COST BREAKDOWN <br /> Piease use this Invoice Cost Breakdov,n as a template for invoices submitted as part of the Backwater <br /> Prevention Device rebate program. Either this form or your own invoice form with lhe following line items can <br /> bc submitted. This allows you to invoice your client according lo your existing biiling template while allowing <br /> city stafi lo identify how costs elig�bte for the Back�•�ater Prevention Device Rebate were accrued. <br /> Only labor and materials direcfly related to the(nstallation and function of a baer half o�h15 /o►mn <br /> device are eligibfe/or City rebate and therefore should 6e included on the upp <br /> Additional cos[s rnay be added(o bottom o(the Iorm. <br /> S�,c�t':,L�'�' � /,�p <br /> Business Name:,Qa�YlP(`jC �i� ��r'(��_�-`;S.1C��License Number. _�S�hK`"� <br /> � r <br /> Dusiness�ailiny Address: o�/�G-� LU/"�rl� j�t�-• /—��'�--U��L�3 <br /> City State Zip <br /> Phone: �Xo'�/0_��Q���_ Email:�,ifl�(C)r_1�('ic3/��� � [L.S,deb�L��'C`�'1 <br /> Categ� Descri tion Units I auantity Rate Total <br /> Administretion Administration/management fiours � _ _ _ <br /> Labor CCTV Inspection _ Hours �_�� <br /> BNN Install Hours _ <br /> Pipe replacement Hours <br /> Surface resloration Hours _ <br /> �— Site deanup f-louts _ <br /> Downsonuts I drainar�e imp. Hours <br /> PcrUnit +� �� � <br /> Materials DaCkwaler valve - -- <br /> Grindcr pump Per Uni� <br /> _t---_ <br /> Side sewer pipe(up to 8 feet) Feet � �� _ �o� _ �.__ <br /> Imported Backfill Yards __ _ <br /> Suriace Restoralion Idialerials Lump <br /> (top s_•oil,grass seed, concrete,etc.)_ sum _j_ _�l7 3(�___ <br /> Cover(irrigotion box or load bearing Per Unit <br /> cover) ----- � a—.J_ol - <br /> Rentals Speci(y equipment Hour <br /> - -- �� ---- –� �a_a_-3a� <br /> F�.�:y Dispooal fees by ilem Yards --7 J <br /> _ _ — � �T���-/--_ <br /> pelivery lees if not covered by labor ._ _ <br /> Eli ible Tatal . i) �_—�—----- — - � ��---�� <br /> Other Costs � s�s not associated with BWD, and <br /> nol e6gible for rebate detail belo�v_ __ __ _ _ <br /> --- -- — J ra c h�c1w= <br /> �1 41 <br /> �- �4 <br /> Ineligi6le Total � � A �'< < <br /> Total —� � ' �J <br /> Revised 9/03/2014 <br />