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BACKWATER PREVENTION PROGRAM <br />INVOICE COST BREAKDOWN <br />Please use this Invoice Cost Breakdown as a template for invoices submitted as part of the Backwater <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 client according to your existing billing template while allowing <br />city staff to identify how costs eligible for the Backwater Prevention Device Rebate were accrued. <br />Only labor and materials directly related to the installation and function of a backwater prevention <br />device are eligible for City rebate and therefore should be included on the upper half of this form. <br />Additional costs may be added to bottom of the form. <br />5'Ce C'rr l� <br />Business Name: 4men (� �1}� c« License Number: _�5 ��4 X <br />Business Mai.ing Address: 4 i46X ec> l F. (l�V w r o <br />City State Zip <br />Phone:X( DGtr> -,Xls; Email:Cia rn/rlrritart � 1l1d S;'�r4prr2°( CY`Ji7 <br />Category <br />Administration I <br />Description <br />Administration I management <br />Units <br />Hours <br />ouanfi <br />Rate <br />Total <br />Labor <br />CCTV Inspection <br />Hours <br />BVJV Install <br />Hours <br />Pipe replacement <br />Surface restoration <br />Hours <br />Hours <br />Site cleanup <br />Hours <br />Materials <br />Downspouts I drainage imp. <br />Backwater valve <br />Hours <br />Per Unit <br />t <br />s <br />Grinder pump <br />Per Unit <br />Side sewer pipe (up to 8 feet) <br />Feet <br />i t rr <br />Imported Backfiil <br />Yards <br />Surface Restoration Materials <br />(top soil rass seed, concrete, etc. <br />Lump <br />sum <br />` <br />3 <br />aD <br />Cover (irrigation box or load bearing <br />cover <br />Per Unit <br />Rentals <br />Specify equipment <br />Hour <br />Fees <br />Disposal fees by item <br />Yards <br />Delivery fees if not covered by labor <br />Eligible Total <br />r A$ <br />Other Costs <br />costs not associated with BWD, and <br />not eligible for rebate detail below <br />G 3 <br />Ineligible Total <br />Total <br />_ <br />$rWA `fib <br />Revised 910312014 <br />