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BACKWATER PREVEiV710N PROGRAM <br /> INVOICE COST BREAKDOWN <br /> Please use this Invoice Cost Breakdown as a lemplate for invoices submitted as part of the Backwater <br /> � Prevention Device rebate program. Either this form or your own invoice form with ihe following line items can <br /> be submitted. This allows you to invoice your clienl according to your existing billing iemplate while allo�ving <br /> city staft'o identify how costs eligible for the Backwater Prevenlion Device Re6ate were acuued. � <br /> Only fa6or and materials directly related to the installatinn and funetion of a backwater prevention <br /> device are eligible for City rebate and Uierefore should be included on the upper half of this form. <br /> Additional costs may be added to boltom of the :orm. <br /> 5�'ctPf�l�-v <br /> susiness Name:��cze�__�_' � c. ' Ie License Number: _��� _ <br /> BusinessMailingAddress: o'�(GL�n L.Gc�'�cVt Yl�-�- �l/i'!T'.�{ l.l.�� ��'.�t13 <br /> City State Zip <br /> Phone:,��-�/D '�?X� _ Email_�Q�yt/�C1s���i�CltSir���N«�'�: l.'cSYI9 <br /> Cate � Desc�i tiort Units puantl Rate Total <br /> Administration Administration!management Hours <br /> Labor CCTV Inspeclion_ Hours � _�S�_ __�� <br /> BWV Insfall Hours <br /> Pipe replacement Hours <br /> Surface restoralion Hours <br /> Site cicanup Hours <br /> Oownspouts/drainagc imp. Houts <br /> Materials Backwater valve _ Per Unit ���� �-�-�{rj _ p2t�_� <br /> Gnnder pump Per Unit <br /> Side sewer pipe(up l0 8 teet) Feet 1< <� ��-���- , _ <br /> Imported Backfill Yards <br /> Surfaco Restoration Materials lump <br /> top soi1, grass seed cLoncrete e[c. sum _ � �� <br /> Covor(irrigalion 6ox or load tioarinD Pcr Unit <br /> cover- ----- --�-- a- �� <br /> Rentals Specify equipmenl Hnur _ <br /> ----—�, �-�p— -- — -- �_ <br /> R�� — <br /> Fees Disposal(ces hy item YardF p{Ly�! <br /> Dclivery fees i(nnt coveied by labor ____ _ ___ <br /> Eli IbleTotal— - - — - - — "� $ <br /> Other Costs Cosis nol associated wifh BWU, and <br /> not eligible lor rebate {delail below __ ' <br /> ----- -- - �,4 f�n a I i <br /> 31J_ <br /> —— —_ � <br /> E <br /> - --- - - %/i,aw «-y �, <br /> . ___ __ � _____ _—.__ __�TI � t�nl.r�/4 �; rb�(� � <br /> Ineligiblo Total � <br /> Total ---- ---- �oZ- - �- <br /> � ---- --- ------- - ------ - <br /> l Revised 9/03/2014 I <br /> �� � <br /> ' I <br />