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—� d s'ri � I�' *F , �� � <br />l. : � �: er .* ' <br />:� i s � � � :�� <br />�� �� �� :.. <br />� - <br />PI <br />ease u�e th'ts lnvoice Cost Breakdown as a#emplate forr o�ri �vo e form vuith��e foilowi�ng i�eatems can <br />Prever�tian Device reb�fe progr�m. Either this form or y�u aur existin billi�g template whiie allowing <br />be 5ubmifted. This alfciws Y�s eli � ble'for therBalckwater�Pre enfiion Device Rebate were accrued. <br />city staff to identify f�ow cost 9 <br />!d be irtcluded on the upper half of this form. <br />I rabor and m�terials directly relaied ta the instaflafr"on and �uncfion of a backwaier preveniron <br />o.� y <br />devrce are e/igible for Cify rebate and therefore s ou <br />Addifional costs may be added to i�ottom of the form. �.� �y� J <br />� ��� u � ��" ��.� <br />����' e <br />� '"� � License Number: � �+�- <br />� ,- ��(}�..�.�..�;��`�+___�__�-- <br />Business Name:, �° ��� �`� l�- t ' t r . � 9 �� �� ��t� �,� <br />, r f_ �� f7 �P ,�i:�,da"��� .i <br />Business Mailing Address: <br />Phane: ��� �` ��� �� k� � <br />Administraiiotl <br />Materiafs <br />Renials <br />Fees <br />p�her Costs <br />Ineligible Total <br />7otal <br />3�escript�on <br />��rniniStratian / mana9emf <br />�C7V Inspection <br />BUVV Install <br />Pipe repiacement <br />Sur#ace restoration <br />Site cleanup <br />r.::..,..,..,.,� �fc t t'li`�.1tri342 ifTl <br />Backwater valve <br />Grinder pump <br />Side sewer pipe <br />1n�ported Backfifl <br />8 <br />Surface Restoration 1�llatenaas <br />{top soil grass seed, concrete etc.) <br />f`nvpr firfiC18tI0n b o Ox ra 1 ad beanng <br />fees by iiem <br />fees if no# covered by iab�r <br />Costs not assvciated with SW�?, and <br />nai eligibie for rebaie (detail be{ow) <br />Revised 9/a3/2014 <br />U n its <br />--- <br />Hours <br />Ho----- <br />HQurs <br />Hours <br />Hours <br />Hours <br />Nours <br />i�er U�ti� <br />Per Unii <br />—�-- <br />Feet <br />Yards <br />l.ump <br />sum <br />Per Uni <br />Hour <br />Yards <br />State z�P <br />