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� �'° ;l s' �l, ` i � �i'« � * ;� `,� ■ -! !�" 4 <br />ii. � � ,_. t. s > <br />�� T� �.� � �.. *£ � „ ;; g � �. <br />Please use this invaice Cast Breakdown as a tempiate far iravoices su6mitted as park af the Backwater <br />Prevention DeVice rebate program, Either this fiarm or your nwn invoice form with the following line items can <br />be submitEed. This allows you to invoice yaur client aecording ta your existing billing template while allowing <br />city staif tn identify how costs eligible for fhe Backwater Prevention Qevice Rebate t+vera a�crued. <br />Only labor and materials direct/y relafed to th� rnstallation and funcfion of a backwater prevention <br />device ar� eliyible �or City rebate and therefore should be included on ihe upper half of �his form. <br />Additiona! costs may be added to battom af the form. <br />��.-- �,/�:� <br />������� << � � � �. <br />Business Name ��'�'��j�,��c (�� `v=�f}�� t�.=�-- �ir^��? License Number: ( �7�j,� ��;�� <br />8usiness Mailing Address: <br />S�ate Zip <br />Phons: ����:, ` '=��(� ��',� ��� �: Email:'� a ���,�?�;,,a �W�' i r��z�� ��?t� r�4���� ;��� r4,��;-r ��"' �'t�Y'� <br />Cate c� Descri fion tlnits Quantit Rate Total <br />Administr�tion Administration / managerner�t Haurs <br />Labor CCTVlnspection Hours - —�,��,,,,�__ `�4 <br />8WV 3nsial! HQurs <br />Pipe replacement Hours <br />Surface res#orafion Haurs � �, , <br />Site cleanup Hc�urs <br />Downspouts / drainage im�. Hours <br />Materials Backwater vaive Per Unit '� ' ' , -��,, ` ��" <br />Grinder pump Per Unit <br />Side sewer pipe (up to 8 feet} � Feet � � "` <br />Imported Backfill Yards _ <br />Surface Resforation Materials Lump <br />to soil, rass seed; concrete, etc. sum `'�.a m(� <br />CQver {irrigafion box or Iaad beari�g Per Unit <br />cover � <br />Renials Specify equipment H�ur <br />� a <br />� � <br />� <br />Fees Disposa! fees by item Yards -'�`�� <br />Delivery fees if.not covered by labor <br />�1�� � �1JF�' l nl�t. � 6,�i.. .. ..... .Q r <br />ti� <br />Other Gosts Gosfs not associated with BWp, and <br />not eli ible fior rebate detail befo4v <br />. . . . �'} s .g^r"r �•,YP:.•b;.--.� s�.::✓'�.'i�€R r.,°;��'..�.i `�.:Yre,�",..a'1p`°� <br />;:•��'"Pe�i��.n,:�. a;;,.�,..�..,� <br />1 c, ��r'.E, �r,?s E v- :k_.a j& <br />f" �%�d'�� �� t;; <br />lneligibte Total $ <br />Total � <br />Revised 9/{?3I20�4 <br />������9� �� <br />