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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 bottomo" of the form. <br /> Business Name: *lb P cc,th Ab9, License Number: 40p✓/no/q®,1/, <br /> Business Mailing Address: 5C/QV `1l9# 4' A1E Ratyydlc, 4/4. 9 .Z7d <br /> City State Zip <br /> Phone: Email: <br /> Category Description Units Quantity Rate Total <br /> Administration Administration/management Hours <br /> Labor CCTV Inspection Hours Lsso <br /> BWV Install Hours <br /> Pipe replacement Hours <br /> Surface restoration Hours ,f y 25 - <br /> Site cleanup Hours <br /> Downspouts/drainage imp. Hours <br /> Materials Backwater valve Per Unit <br /> Grinder pump Per Unit <br /> Side sewer pipe (up to 8 feet) Feet <br /> Imported Backfill Yards <br /> Surface Restoration Materials Lump <br /> (top soil, grass seed, concrete, etc.) sum <br /> Cover(irrigation box or load bearing Per Unit <br /> cover) <br /> Rentals Specify equipment Hour <br /> Fees Disposal fees by item Yards <br /> Delivery fees if not covered by labor <br /> Eligible Total $ <br /> Other Costs Costs not associated with BWD, and <br /> not eligible for rebate(detail below) <br /> Ineligible Total $ <br /> Total $ <br /> Revised 9/03/2014 <br />