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1 <br /> � <br /> ��1�iCVi/ATER �R�VIE(V°1'IOIV PROe'aRAN! ' <br /> IBVVC�B�E COSi' ��EAlC�OWN ; <br /> Please use this invace Cost Breakdown as a templete for invoices submitted as part oi the Backv,ater � <br /> Prevenfion Device rebate program. Either this form or your own Invoice form wfth tha following line ftems can j <br /> be subm�tted. Thi�allows you to invoice your dient according to your existing billing femplate while allowing i <br /> ciry slafl to identity howr oosis eligibie fa tfie Backwater Prevention�evice Rebate were accrued. <br /> Orery Iabar and materials directfy relat�d to 6'ae insfellation and tunction o0a backwater pneveastlon j <br /> devfce ere eligdble lor City nebate ar►d AhssePnre shautd be rnclud�ore the t�pper haH o/thVs form. � <br /> Additional cosfs may be added to baMom ot the fonn. � <br /> � �d yl �� license Number.__�'���U �f��� � <br /> Business Name: j <br /> Business Mailing Address: ,�►ff�l �� d i� �-�� �Y`'" �P�{-�� 9[�'L�� ' <br /> St e . � Zip . <br /> Phone: L�,2�- ���P—�[Z-�3 Email:_��iV��o�`1 e-L-4���� <br /> � <br /> Cae o Descei fon UnNs QueM� Rate Totel � <br /> AdminisMaOon AdminisUationlmanagement Hours t <br /> t,a6or CCN I�pection Hours / <br /> BWV Install ' Nours / <br /> Pipe replacement Hours j <br /> Surface restoratlon Hours j <br /> 5'de deanup Hours / <br /> Downspouts I drainage imp. Hours ! <br /> INaterlals Backwaler valve Per Unit ���� <br /> G�inder pump Per Unil , <br /> Side sewer ipe(up to 8 teel) Feet ; <br /> Im[wrted Bacld�' Yards ; <br /> S Surface Res0ora6on Ma�erials Lump / J�j i <br /> to soil, rass seed,wnr.rete,etc. sum �l <br /> Cover(irtigation box or load bearing Per Unit � <br /> cover <br /> Hour i <br /> Remais Specify equipment ' <br /> i <br /> r-� Disposal fees by ilem Yards � <br /> — d � <br /> , Delivery fees H not covered by labw _ ` <br /> — . � <br /> Eli ible To4ul $ ' <br /> Casts nol associated with BWD,and � <br /> Other Costs � <br /> not efigible Tar rebate delall below � � 3 <br /> -- r+� i <br /> � <br /> _ j <br /> 3�-° I <br /> � 1� I <br /> IneligiWe Total i <br /> � <br /> Totat $ I <br /> i <br /> � <br /> Revised 9/03/Z014 � <br /> � <br /> i <br /> i <br />