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. � .. � �,. �;. ,� �, . ;. <br />� ' i �` ` `I <br />�. � � `� i .r' � <br />Pfease use fihis Invoice Cost Breakdown as a templafe for invoices submiite�i as paet of fhe Backwater <br />Prevention Device rebate program. �ither this fiorm or your own invoice fiorm with the follawing (ine items can <br />be submitted, This allows you to invoice your client aecording to y�u� existing biliing template while allowing <br />city staff #o identify how costs eligible for the Backwater Prevention Device Rebate were accraed. <br />Onty labor and materials directly related fo fhe instatlafion anat funcfion af a backwafer prevenfion <br />device are eligihle for City rebate and fherefore should be included on the upper ha/i` of fhis form. <br />Additional costs may be added to botfom af fhe farm. <br />�Nz�'�- L'�' <br />Business Name;��1�=���,�,���j ���f,��-- 7rt�� License Number: f,.��j����lj'� <br />Business Mailing Address; <br />City State Zip <br />Phone.,:.��:�t`1 ',�'�"'��� Email;���"1r��1��-i�.��ri ��}-��;.�.�r�'�� �'�i�r�,�,r2�.�"� �''�� <br />Gate o pescri tion Uni#s Quanti Rate Totat <br />Administration Adminis#ration / management Hours <br />Labor CC7V Inspection Hdurs "�� <br />8WV Install Hours <br />Pip� repiacement Hours. <br />Surfac� restoratiati Hours <br />� <br />Site cleanup Hot�rs f <br />Downspouts / dtainage imp. Hcturs <br />Maierials Backwater vaive Per Unif •�"" � �' <br />Grinder pump Per Unit <br />Side sewer pipe (up to 8 feet) Feet v �; <br />imparted Backfil Yards <br />Surface Restoration Materials Lump <br />to soil, rass seetl, concrete, etc. sum C.�. �� <br />Cover (irrigation bax or load bearing Per Unit. <br />cover � �- <br />Rentals Specify equipment Hour <br />--� :e'�� <br />Fees Disposa! fees by ifern Yards <br />Dei�very fees if not eovered by tabor <br />Eti ible Totai . , .� , $ : � , . <br />Other Costs �Osts nOt assOGiated with BWD, ertd <br />not eli ible for rebate detaii be.low <br />� 1z, �. �Lc��' ��`��fi. �� �+r��. <br />'T�,' , <br />' ,�,. t� <br />lneligible Total $ 1 / ��(t G <br />Toial $ �j <br />Revis�d 9/Q3/2094 <br />b ��� ��� <br />, <br />