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BACKVIIATER PREVENTION PROGRAM <br />INVOlCE COST BREAKDOVUN <br />Please use this Invoice Cost Breakdown as a tempiate for imioices submitted as part of the Backwater <br />�, Prevention Device rebate progr�m. Either this form or your own invoice form with the folioH�inc line items can <br />be submitted. This allo�vs you to invoice your client according to your existing biliino templal� !vhile allowing <br />city staff to identify how costs eligible for the L3ackwater Prevention Device Rebate a�ere accrued. <br />e�nly labor anJ materials directly related to the installation and f�nction af a backwater prevenfion <br />device are eliglble (or Ciry re6ate and t�herefore should be included on the upper half of U:is form. <br />Addrtiona! costs may be added to bottom of the form. <br />1� �'!' l,L(.� <br />BUsiness Name:.��L�Qcj1�5License Number: _Q�� __ <br />Business Mailiny Address: <br />Zip <br />Phone: � 1 �.�IL> �:�YS�'�l Email:_���js����(}}i�1.;/�!j �S�d���,:r •��'� <br />Revisod 9/03/2014 <br />