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BACKWl�TER PREVEiVTIOiV PROGRAM <br /> � INVOICE COST BREAKDdWN <br /> Please use this Invoice Cost Breakdown as a tempiate for invoices submilted as part of the Backwaler <br /> Preveniion Device rebate program. Either this form or you;own invoice form with Ihe following line items can <br /> be submitted. This allows �ou lo invoice your clienl according to your existing billing template while allowing <br /> city staff to idantify how costs etigibie for the Backwater Prevention Device Rebate were accrued. <br /> Only labor and materials directly re/afed to the installation and funcfion of a backwater prevenfion <br /> device are eligible for Ciry rebate and therefore should be included on the upper haff of this form. <br /> Additional costs may be added lo bottom of the (orm. <br /> 5���'�,��� /' <br /> Business Name:�,mv��,,�� ��(}}�C,��i�F License Number. _(aS��i�`�:� <br /> � <br /> BusinessMailingAddress: o��l'.L� �.G't il�l C/(�-• !--;,�'�'�f l,(�� ��'�(�� <br /> City State Zip <br /> Phone:,�•.�JO �',�'?S;=,L Email:�'.i ��in/�1NI'i�� c� g � ������N(', Cc�� <br /> Cato o Descri tion Units Quanti Rate Total <br /> Administration Administrationlmanagement Hours <br /> Labor CG7V Inspection Hours ��� ��� <br /> BUJV Inslall Hours <br /> Pipe replacemeut Hours <br /> Surface restoralion Hours � <br /> Sile cleanup Hours <br /> Downspoul�I drainage imp. Hours <br /> Materials Backwater valve Per Unil _� <br /> Grinder purr.p Per Unit <br /> Side se�ver pipe(up to 8 feeQ Feet t/' ° <br /> Imported 8ackfill Yards <br /> Surface Restoralion Materials Lump ..) �� <br /> m soil,_4rass seed, concrete, etcJ sum <br /> Cover(irri9ation box or load bearing Per Unit � '� <br /> cover <br /> Rentals Specify equipment Hour <br /> — -�t'�i.cl� e -- �� <br /> Fees Disposal fees by item Yards o_� � <br /> Delivery fees if not covered by labor __.. <br /> Eli ible Total � �- �' � <br /> Othcr Costs Cosis not associated with BWD, and <br /> nol eli ible for rebale detail below <br /> a p�1��.,, clvr <br /> �--v � <br /> � <br /> Ineligible Total t $Gw.�a�r 4 ������ <br /> Total � �" <br /> Revised 9/03/201� <br />