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BACKWATER PREVENTION PROGRAM <br /> INVOICE COST BREAKDOWN <br /> Please use this Invoice Cost Breakdown as a template for invoices submitted as part of ihe Backwater <br /> Prevenlion Device rebate program. Either this form or your own invoice form�vith the following line items can <br /> be submitted. This allows you to invoice your client according to your existing billing temp!ate while allovaing <br /> city staff fo identify how costs eligible for the Backwater Prevention Dovice Rebale tvere accrued. <br /> Oniy laborand materials directly reiated to the installation and function of a backwaterprevention <br /> device are eligible for Crty rebate and therefore should be incfuded on the upperhalf of lhis form. <br /> Addifional costs may be added to bottom of the form. <br /> �4i}o� '� �+�'/'� Q <br /> Business Name: _GL��i�.�w21� License Number. � ��S 1 � � <br /> Businessh4ailingAddress: �0�� ���f)� S�,J�•�L?`�� wf�} Q�a6 <br /> � /�� p ���I C� p State Zip <br /> Phone:�' `7f/�� yl!3 Email: a 7c a�ase:,�e� (�6hui l. c.o��, <br /> Cate o Descri tion Units Quanti Rate ToWI � <br /> Administration Adminisiration/management Hours ; <br /> Labor CCN lnspeclion Hours _ �_ .�j �S,pQ � <br /> _ _ __ BVtN Inslall Hours nf J� � O,QO � <br /> Pipe replacement Hours t <br /> Surface resloration Hours <br /> Sile cleanap Hours _ i <br /> Downspouts/drainageimp. Hours <br /> Materials Backwaler valve Per Unii __ 'J�p ,OQ��OO {� <br /> Grinderpump PerUnil _ _ _ � <br /> Side sewer pipe(up to 8 feet) Feet _ <br /> Impotted Backfll Yards <br /> Suriace Restoration t�9aterials Lump <br /> (top soil,grass sced,concrele,elc. sum ��� �' � <br /> Cover(irrigalion box or load bearing Per Unit O � �� OO <br /> cover � ��__._ � <br /> Rentals Specify equipmenl Hour <br /> -- - --- -- � <br /> Fees Dispos�l fees by ilem Yards 1 � �O�O '�C'>_bU � <br /> --- ---— -�——— <br /> r <br /> Delivery(ees i(nol covered by labor ' <br /> - `------- - - -- �C���G� <br /> Eli iblc Total ^� <br /> Other Costs Cosls not associaled with CiV1'D,and <br /> _ __ nnl eligibie(or rebale(detail below) ___ <br /> --I -----��� � t���- <br /> — - -- --- -1=1,-��_—__b -t�-�{ _ � �� <br /> Ineligible Total U $ <br /> Total _M�� $ _ <br /> __ _ f�1� � � <br /> �1..-�$' l� <br /> Revised 9/03/?014 <br />