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� '�` � r 1 � t�. �" � • ;� � ,. ■ �, <br />�w - � <br />-� <br />�� -�– „ � ' *� a��`� � � �" - �" � .� :� <br />r'' .�..k .i' �,% � <br />Piease use this Invoice Cast Br�akdown as a template far invaices submitted as pari of tha Backwater <br />Preven#ion Device rebaie pragram. Eith�r this farm or your own invoice #arm with the follawing line items can <br />be submitted. This allows you fo invoice your elienf accarding ta your existing biHing templafe whiie ailowing <br />eity staf� #o idenfify how costs sligible far #he Backwater Prevention Device Rebate wera accrued. <br />Only labor and maferials direc#ly relafed to the installafion and function of a backwater prever�f�on <br />device are eligible far City rebate and therefore �hou/d be included on the upper half of fhis form. <br />Additional cosfs may be added to botfom of the form. <br />��'''''}, �-- "�.,�.�/� / <br />� `✓ �"�Z"�y � o–, � '7 w^'� d� <br />Business Name ���,��� �e-f;��~� �r� ) �.�.. •,�rr'���? License Nvmber. ��-=�� �'� ___ <br />� <br />Business Mai(ing Address ��%�-t�% [_.G=��'".��.l�i ��rK--� ���`r�.�t`�'� �-s'.�`r, ,�`r ���r �.��..__� <br />City Sta�e Zip <br />�'"�/''y/y �1. �^,,+� <br />��Qil�`.�'y��%7"d.'3i`iV �"h�t�,ry'ty'��✓" Em�ai1�S�.a�P�+��1�Y.d`�"'At"-/l�d�il{�v"' ..r'.�4"�.� ���I�i��%i+�d �.1y�1� <br />�,. <br />Cate a 13escri tion FJnits Quanti Rate Totat <br />Administration Adminisftation / management 1-lours <br />Labor CCTV Inspection Hours <br />8WV Instali Nours <br />Pipe replacemenf Hours _ <br />Surface res#orafion Hours �� <br />Site c{eanup Hours � <br />Downspou�s ! drainage imp. Hours <br />Maieriats Backwater valve Per Uni# r <br />Grinder pump Per Unit <br />5ide sewet' pipe (up to 8 feet) Feet � C� � <br />{mported Backfill Yards <br />Surface Restoration Materials Lump <br />top soil, rass seed, concrete, etc. sum �� <br />Cover (irrigation box or laad bearing Per Unit <br />. <br />cover <br />Ftenfals Specify equipment Hour <br />� <br />Fees Disposal fees by iYem Yards <br />DeEivery fees [f not covered by labor <br />Eii ibte Tota! � � ;' <br />Other C�osts C�sts rto# associated with SVV�, and <br />not eli ible for �eba#e detail below <br />•"=4.��> � �:��.� yx.w•m a.�c+c'���� <br />;ii� .v <br />-� �� ��r <br />�- �: �� <br />Ineiigible Tatai � <br />Tatal � <br />Revised 9/03/2094 <br />