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BACKWATER PREVENTIOfV PRaGaAM <br />� INVOICE COST BREAKDOWN <br />Please use lhis Invoice Cost Breakdown as a template for invoices submitted as pa� of the Backwater <br />Prevention Device rebate program. Either this form or your ovan invoice form �vilh the follov�ing line items can <br />be submilted. This allows you to invoice your client aaording to your existing biliing lemplate while allowing <br />city staff to identify how costs eligible for the Back�vafer Prevention Device Rebate were ac�rued. <br />On!;�'abor and materials direcUy related to the insiallati�n and funcflon of a b e�� �f o�his formn <br />devicc are eligible for Ciry rebate and therefore should be included on the upp <br />Additional costs may be added fo bottom of the (orm. �� <br />5��.`�`�, � 05;�:5�`�— <br />Business Name:�j.(1_u2��7-L�5�- License Number: n <br />_ .� .. /1r.__ ' <br />BusinessfvlailingAddress:GSl��tt% �i l��� ""`"' —' City State Z�p <br />Phone:�;io•��•,"�1�� Email:(�(lIl��nnt�r'ir_�n_�� G ���dt'!a-�2'(',Cr�3�J <br />Revised 9/03/2014 <br />4,.u.y <br />