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BACKWATER PREVENTIO�I PROGf�AM <br />INVOICE Cd�T BR�AiKDOWN <br />Please use this Invoice Cost Breakdown as a template for invoices submitted as part of the Backwatcr <br />Prevention Device rebate program. Eilher this torm or your own invoice fortn with ihe followiny line items qn <br />be submitted. This albws you to invoice your dient aocording to your ezisting billing templale whilo, albwing <br />city staff to identiry how cosis eligible for the Backwater Prevention Device Re6ate were accrued. <br />Onty labor and materials direcfly refated to fhe lnsfallafion arrd funcdon of a baakwater prevention <br />device are eligible for Ciry rebate and theretore shou/d be included on the upp� helf ot Mis !om►. <br />Addftional costs may 6e added to botfom oi Ure form. <br />Business Name: �-$�IUn� b I�'Q �L C License Number. ��������' �7/ P� <br />Business Mailing Address: 1r'� CO �� V� �'tCl,V�[LY!'L2 i�'�� �V-Pile.�� �vi4 �'�-'t"t-� 1° : <br />City State Zip - <br />Phone: ���� �� 1���- OlZ?j _ Email:_(LL ���•m /oif'Zq LL C. i�% �_..���ffir -. L e>"'1 <br />--r <br />1"1 `� I�1 Sµ �.��j l�L-f ic� I., <br />Revised 9iD32014 1( �� � <br />