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BACKWATEF� P��VENTIO(V PR�3CRAM <br />INVOICE CCyST BREAKUO��VN <br />Please use this Invoice Cost Breakdown as a tempiate for invoices submitted as part o!'the Bac!avater <br />Prevention Device rebate program. Either this form or your own invoice form with the following line items can <br />be submitted. This allows you to invoice your clfent according to your existing billing templal� while allowing <br />city staff to idenfify how casts eligible for the Backwater Prevention Device Rebate wem accrued. <br />Only labor and materfals direcNy nelafed to the lnstallation and funcHon of a backwater preventioa <br />derice are eligible fo► City rebafe and therefore should be included on the upper haH oi thfs fortn. <br />Additronal cnsts may be added to bottom of the form. <br />Business Name: �j-� i��INYIYJ!!1c( -� � License Number: f/}D�-,ti�� ���n � <br />Business Mailing Address: YS G� (-� <br />Phone: HZ �'" !_f 8�'" lj� Z—�� <br />Labor CCN Ins ection <br />BWV Install <br />Pipe replacement <br />Surface restoratlon <br />Site clsanup <br />Downspouts / drainage imp. <br />Materiois Backwater valve <br />Grinder pump <br />Side sewer pipe (up to 8 feet) <br />Imported Backfill <br />Surface Restoration Materials <br />to soil, rass seed, concrele, etc. <br />Cover (irrigation box or load beanng <br />oo�er <br />Hentals Specify equfpment _ <br />F Disposal tees by item <br />Q '� <br />_ Delivery fees if not covered 6y labor <br />Eliai6le Totnl <br />Other Costs I Costs not <br />__� ..�:..:�� <br />Revised 9/03/?1i14 <br />and <br />�� <br />Hours <br />Hours <br />Hours <br />Per Unit <br />Feet <br />Yards <br />Lump <br />sum � <br />Per Unit r <br />Hout <br />e <br />2S <br />'1 � <br />� <br />