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�,r.k. tl�? :�q $ ` �" .��' �II, � .:a�P �� � �� :�". � °�. <br />��Ai1�1� , ! €� +Y a E-�e. '' ._. * � ? <br />� �' . � � is= :,• i. �i � <br />Please use this invoice Cost Breakdi�wn as a template for invaices submitted as pa� c�f the Backwater <br />Preventian Device rebate prograrn_ Either this form �r your own invoiee fiorm with the fio(lowing line items can <br />be submitted. This ailovvs you to invaice your c(ient according fo your existing bifling template while a(lowing <br />city staff to idenfify how costs eligibte for the Bacicwater Prevention Device Rebate were accrued. <br />On/y Jabor and materials directly related to the installation and function of a backwat�er preveniion <br />device are eligible for Cfty rebate and iherefore should be included on Phe upper half of this fc�rm. <br />Additiana! costs may be aclded to bottom af the form. <br />�'�`G�� �� <br />Business Name;��^��� k—� ���-,t-� �°} ��.G.�;:� ;'7ie^�� Lieense Number. t'°�'�`.>� ����� � <br />Y Y <br />Business Mailing Address: r.�ilv�.�-�� L.�=� �"�� �/i 4`�+ tf�--� ��, ��d �`�`f (.��`r�-1 �'� �'��(��-� <br />City State Zip <br />Phone::�..�J.-��.�C� ,�'�"k�'�-"=� Emaii:���'��$a`'�y�'�s``�trx�;��.� � �:���`�� �,ar��,�,.�=�r.P�.� �°c`'i�'"}'� <br />Cate o Descri tian Units Quanfi Ra#e 7oiat <br />Adminisfir�tion Rdministration f management Hours <br />Labor GCTV inspection Hours <br />BWV Instatl Not�rs <br />P�pe repiacement Hours <br />Surface resto�ation Hours � <br />Sit� cleanu� Hours <br />Downspoufs � drainage imp. Hours <br />Materials Backwater value Per Unif -�- �; <br />G�inder pump Per Unit <br />Side sewer pipe (up to 8 feet) Feet +� f <br />Imported Backfil! Yards <br />SurFace Restoration Materials Lump <br />top sail, rass seetl, concrete, etc. sum � �a ;�'j <br />Cover (irrigation box or load bearing Per Unit <br />cover �.. �- <br />Renials Specify equipment Hour <br />� . � <br />Fees Disposai fees by item Yards �. <br />Delivery fees if not cavered by tabor <br />Eligible Total _ -. . < $ r . <br />Other Casts G���� ��� �����«��d wifh BWD, ahd <br />nat e[i ible forrebafe detail beiaw <br />� � � � � <br />� <br />� <br />t '+� .� �t <br />Ineligible To#al ` ,�""f <br />Total � `' <br />Revised 9/03/2094 <br />