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� BACKWATER PREVENTION PROGRAM <br />� � INVOlCE COST BREAKDOWN <br />Please use this Invoice Cost Breakdown as a template for invoices subiriittod as pa�i of the Backwater <br />� ���vention Device rebate program. [ifher this form or your own invoice form with the following lin� items can <br />be : hmitted. This allows you to invoice your client according to your exisiing billing template whil� allowing <br />city stafi to identify how costs eligible for the Backwater Prevention Device Rebate were acerued. <br />Only /abor and materials directly related !o the installation and function of a backwaferprevenfion <br />device are eligible for City rebate and therefore should 6e included on the upper half of this form. <br />Additional costs may be added to 6ottom of the (orm. <br />5�'C�'�� �'`' `y '\ <br />3usiness Name; Q�(�.(�.�'7 �C' G`�•���'�'— License Number. _�ST�� ^_ <br />Business Mailing Address: bf(GC�(c; +..urr� v� u�'�-� � ��y" ``t"' Siate Zip <br />Phone:.�v-�1C� %al2�.a� Email_�' � ��> �mrrj��zn��,�C.ltld_.�x��b�,2"(: CYi3'Yl <br />Revised 9iO3/2014 <br />