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� ' s � A s r • � � "' � " A <br />r <br />� � � �' �' t � �. <br />��I��� ' <br />Please use thys lnvoice Gast Br�akdown as a template for invaices submitt�d as part of the Backwater <br />Pr�v�ntion Device rebate prograrr�. Either this form or your own invoic� f�rm with the following line items �an <br />b� submitted. This afiows you to invaice yoc�r clier�t according io your existing biiling templat� while afl�win� <br />city staff to identify how cnsts �ligibte for the Backwater Prevention D�vice Rebate were accru�d. <br />pnly l�bor and materials direc#ty relafed to fhe install�fivn and tunction ,vt a backwater preventian <br />device are eligible #or Cit,y rebate and therefore shou/d be inciuded on the upper half of fhis form. <br />Ad�itional costs may be added to battom of fhe form. <br />Busin�ss Name: _�-��� � � f �-� �,,,,�.,..:.�..._ LiGense Number: �� � �%�'� <br />Susin�ss Mailing Add�ess: � �L2 � .�� �`�� �G�-�� � �'�=� '�^"�- � �` �� <br />� Cit State ip <br />Phone: .�'���"_ � � �'� : L� ��.� Em�il: < � �° ` �. ` - . � t��Z.,�.., <br />Administration Admfiiskration / <br />L,abor CG'N Inspectia <br />BWV Inst�ll <br />Surface restaeatian <br />Site cleanup <br />Downsoouis / drainaqe im <br />Mat�rials Backwater valve <br />Grinder pump <br />5ide sewer pipe (up ta 8 feet) <br />Imported Baakfill <br />Surface Restoration Materiafs <br />to soil, rass seed, concrete, etc. <br />Cover (irriga#ion box ar load bearin� <br />I f�es bv item <br />if not covered hy labor <br />Q#her Custs � Costs not associated with BWD, and <br />not eliaible for rebate (detail below} <br />Ineligible Tatal <br />�Ot��. <br />Revised 9IU3/21J14 <br />units <br />Fiours <br />Hours <br />Ffcaurs <br />Ho�+�s <br />Hours <br />Hours <br />Per Unit <br />Per Unit <br />F��fi <br />Yarcis <br />Lump <br />sum <br />Per Unit <br />Hour <br />� <br />� <br />��� i�� <br />�E�� +!,� , ��� <br />