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BACKWATER PREWENTION PROGRAM <br /> INVOICE COST BREAKDOWN <br /> Please use this Invoice Cost 6reakdown 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 alloevs you to invoice your clienl according to your existing billing iemplate 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 installafion and Iunctlon of a backwater prevention <br /> device are elig)ble for Ciry re6ate and therefore should 6e included on the upper half of this form. <br /> Additional costs may be added to 6ottom of the form. <br /> �������� /,� <br /> Business Name:�l ri��¢i� ���•6 r�e License Number. _{��r'7��`T.\ <br /> BusinessMailingAddress: oZfil.tv L.EL/"��l�l r1f�-• r��L� l-��A ���t�� <br /> City State Zip <br /> Phone: ��`�Lc� ";�u-� Email:��>n/Yl�/'i�an�� "�r;n�j s��ie�r�r2"�' CYiYYI <br /> Cate o Descrl tlon Units Quanti Rate ToWI <br /> Administration Administrationlmanagement Hours <br /> Labor GCTV Inspection Hours <br /> BNN Install Hours <br /> P;pe replacement Hours <br /> Surface restoration Hours <br /> Site cieanup Hours <br /> Downspouts/drainage imp. Hours <br /> Materlals Backwater va�ve Per Unit j - <br /> Grinder pump Per Unit <br /> Side sewer pipe(up to 8 feet) Feet �� ` <br /> Imported Backfill Yards _ <br /> Surface Restoration Materials Lump <br /> to soil rass seed, concrete,etc. sum a� <br /> Cover(irrigation box or load bearing Per Unit t � <br /> cover — <br /> Rentals Specify equipment Hou� <br /> �- <br /> Fees Disposal(ees by item Yards <br /> Delivery fees if not covered by labor <br /> Eli ible Total � � $ <br /> Othor Cosb Costs not associated wilh BWD, and <br /> not eii ible for rebate detail below <br /> — 4 t� �..�.-� N 13 <br /> 7ti�-�-- � <br /> �,»i...« <br /> IneligibleToWl $ wJ2L/I3' <br /> Total $ <br /> Revised 9/03/20i4 <br />