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� �; :X j � �'" �1r: r # �� �' .n ,�` .l. � <br />°� � � � `� � A <br />, '� �: � <br />Please use this Invaice Cost Breakdown as a tempiate for invoices submitt�d as part af the �ackwater <br />Preventian Dev[ce rebate program� Ei�her this i'Qrm or your ovun invoic� farrr� with the following iine it�ms can <br />be subrnitfed. 7his aPlows you to invoice your client according ta your existing �illing template while a�lowing <br />city staff to iden#ify how cosis eligible for the BackwaterPreuention Device Rebate were accrued_ <br />Only la,bor and materials directly related ta the instaUation and function of a backwater prev�+�tion <br />device are eligible for City rebate and fherefore shoul�d be inc/uded on ihe upper half of ihis form. <br />Additional costs may be added to bottom of the form. <br />�-- '�,,,Ls �.� <br />�4C✓�r � � � ��� <br />Business Name: �•����-, �;r�f3i�,� yt�-���tt'�l�' License Number. t_.��_�� � <br />Business Mailing Address: r"�6G:%��.� C.�=z �'°"�c 1t't �J �r:--� �,�fi'�l"t�:7 {:�`✓r`� "r C��t ?..:.� <br />City State Zip <br />Phone:��,� �`.���, �-�"�i`�::� EmaiLf� � i�����'�����f�� c�� �°�,� ��..,���-� ��� ��-; t ���"w �.�� <br />�ate o [3escri tion Units Quanti Rate 7otal <br />Ad►ninisfiraiion Administration ( rnanagemenf Hours <br />Labor GCTV Inspection Hours <br />81lV1/ InstaEl Haurs <br />Fipe replacement Hours <br />Surface restaration Hours , :y <br />5ite cleanup Hours <br />Downspouts / drainage imp. Hours <br />Materials Backwaier �alve Per iJnif � � ° �`' <br />Grinder pump Per Uni# - <br />Side sewer pipe (up to 8 fieet) Feet r c ,�� <br />imported Backfill Yards <br />5urface Restoratian Materials Lump . <br />top soil, rass seed, concrefe, efc, sum � �_ <br />Cover (irrigation box or load bearing Per Unit <br />cover � <br />Rentats Specify equipmenf Hour <br />'7 4_ <br />Fees Disposal fees by item Yards c <br />DeiivEry fees �f not covered by tabar <br />�tigibieTotat ,.�;. .� $ _ <br />Other Costs Costs not associated with BWD, and <br />110# @�l 1bf2 fOt' f8�?�t8 detail iaelow} <br />`' ��. >'. x�:�� ; �� ,� i-::�' :;'-�ar'��' � ��`� �:� �_� <br />.m��a��Q,-. �•� <br />"b=i€�,&- tt„.�-�,x-.::3�a <br />�#? ��� {;s <br />(neligibie Totai � > <br />Total $ ` s� . <br />Revised 9/03/2414 <br />