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ESAf;KWATER PREVENTION PROGRAM <br /> INVOICE COST BREAKDOWN <br /> Please �se thi, Invoice Cost Breakdown as a template for invoices submitted as part �f ihe Backwater <br /> Prevention Device rebate program. Either this form or your own invoice form with the foliowing line items can <br /> be submitted.Th�s allows you to invoice your client according to your existing billing iemplate while allowing <br /> city staff to identify how costs eiigible for ihe Backwater Prevention Device Rebate were accrued. <br /> Only labor and materials directly related fo the insta!laGon and function of a 6ackwater prevention <br /> device are efiglble for Clry rebate and therefore should be included on the upper half of this form. <br /> Additional costs may be added to bottom of the firm. � 'Z.�'L 1 vY,�„",�r(, <br /> cS�c.�f.� <br /> Business Name:�(-j���ri �l�iG�i�License N��^:!,er. Q55�3�_ <br /> r% /� � � ) <br /> BusinessMailingAddress: o�"� LGt("�4t �_l��_-_(d�J�� 13 <br /> City State Zip <br /> Phone:,�.,�IC� -:��'�l Email:�,i��.�i'i���H-i�r]nA 5;���Y'!: Cc <br /> Cate o Deseri tion - -- Units Quanti Rate Total� <br /> Administration Administration/management Hours <br /> Labor CCTV Inspection Hours � C ^ (1 <br /> gWV Install Hours _ <br /> Pipereplacement Hours ., �r, y��-�-�" P� - <br /> Surface resloralion Hours 1��P -"" ' <br /> Site cieanup Haurs _ <br /> Downspouts/drainage imp. Hours <br /> Matertals Backwatervalve PerUnit ��' -���,� ;:'S <br /> Grinder pur„p Per Unit � <br /> Side sewer pipe(up to 8 feet) Feet �' r' G���� <br /> Impoded Backfill Yards _ __ <br /> Sudace Restoration Materiais Lump <br /> __(top soil, rass seed_concrete etc]__ sum_ _ J� r C� <br /> Cover(irrigation box or load bearing Per Unit <br /> cover) -- --- -- ----� ---��-- - <br /> Rentals Specity equipment Hour <br /> --------� -- —— <br /> Feas Disposal fees hy item _ _ Yatds ____ __ __.��� <br /> -- �t <br /> Delivery fees if not covcred by labor _ _ <br /> Eli ible Total � � $ � <br /> Other Costs Costs not associated with BVJD,and <br /> nol eligible for rebate(delail below <br /> --- � - -�� - ° -- <br /> ��---- � - - - -- <br /> Ineligible Total L� � � <br /> � Total $ _ <br /> (6v\�--y�- �7�-- <br /> � i � <br /> � Z..- ,� � �� <br /> Rovised 9/03/2014 <br />