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BACKWATER PR�VENTION PROGRAM <br />INVOICE COST BREAKDOWN <br />Please use this Invoice Cost Breakdown as a temptate for invoices submitted as paR of ihe Backwater <br />Prevention Device rebate program. Either this form or your own invoice form wilh the fallowing line items can <br />be submilted. This allouvs you to invoice your client according to your exis6ng billing template while allowing <br />city staft to identity how costs eligible for the Backwater Prevention Device Rebate were accrued. <br />OMy labor and materials dlrectly re/ated tn the insM7lation and /unction o/ a backwater prevention <br />devlce arc elFgible tbr City rebate artd thereMre should be inc/uded on the upper hal/ o/ this Iorm. <br />Addifional costs may be added to bottom of Nre lorm. <br />BusinessName: a9-/�-��v�,�h�� [( f LicenseNumber. /�19����A//f /7 <br />.� <br />Phone: L�2� � g �7— <br />Revised 9/0.3/2014 <br />