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BACK{nfATER PREVEiVTION PROGRAM <br />IIVVOICE COST BREAKD011V��1 <br />Please use this Invoice Cost Breakdown as a templaie for invoices submitted as pari oi the Backv✓aler <br />Prevention Device rebate program. Eilher this form or your own in �oice form with the follo:roing line items can <br />be submilted. This allows you to invoice your client according to your existing'billing iemplate �vhile allowing <br />city staff to ideniify how costs eligible for the Backwater Prevention Device Rebate were accrued. <br />Only labor and materiais directiy related to the installation and function of a backwatcr prevention <br />device are eligible for City rebate and therefore should 6e included on the upper half of this form. <br />Additional costs may he added to boftom of the form. <br />S�eccs' ; L.L,c: <br />8usiness Name:.�(�j (f�1�_6��--�;:'_�i 1�' , License Numher: ��S���t_� <br />Business Mailing Address: oSlcLcn LGtI Icb�� ����-• �-�1`^ `'" State Zi <br />City P <br />Phone:�'I�'�Gtl�-,�'?.�'� Email: • �� ,1k1���rca4 � G d S�d�,Crn?° ,r�77'1 <br />Materials <br />I Rentals <br />� <br />�___ <br />� Fces _ <br />li --- <br />l <br />Eli ible Tot. <br />Othor Costs <br />Total <br />Administration / manageme <br />CCN Inspection <br />gWV Install <br />Pipe replacement <br />SuAace restoration <br />Site cleanup <br />Dot^�nspouts / drainage imF <br />Backwater valve <br />Grinder pump <br />Side sewer pipe (up to 8 f2 <br />Imported Backfill <br />Surface Restoralion Materi <br />(top soil qrass seed, conci <br />Cover (irrigali�n box or loa <br />coverl <br />Specify equipment <br />.-r�r,c���- � <br />Disposal fees by item <br />Dellve fry ees if no[ covera <br />—T� c,�c n� <br />Cosis nol associated �vilh' <br />not eli ible for rebale del� <br />Revised 9/03/2014 <br />Units <br />Hours <br />Hours <br />Hours <br />Hours <br />Hours <br />1 Per Unit T � <br />Per Unit <br />,� Feet ��- •' <br />Yards <br />s Lump <br />te, etc. sum � <br />be�ring Pcr Unil <br />Hour <br />and <br />� <br />7� <br />