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����� :: "� � � >i' ��� .` + � �' :! �' 1: <br />�� f � <br />T' ,, ,� t �d :�t' R <br />��i , ° �� t �''� <br />� ; } � <br />, ' � .� � �,. <br />f'lease use this inv�ice Cost Breakdown as a femplate:far invoices submitted a� part of the Backwater <br />Prevention Deuice rebate program. Either this form or your own invoice form with the fiollowing' line items can <br />be submitted. This �{Iows you to invaice your client according fio your existing biiling template whife allnwing <br />city sta�F ta identify how �osts el�gible far the Backwater Prevention Device Rebate were accrued. <br />Only labor and m��eriats direcfly related fa the installatron and function of a backwater prevention <br />device are eligible for City rebafe and fherefore should be ir�cluded on t'he uppel' half of fhis fot`m. <br />Additional cosfs may be added to bottom of the farm. <br />���G.��-,"��- �. c� <br />Business Name ,'������ ���, t�o ��t'3��� ��;�tt"���'.� License (Vumber: �:`����,��r <br />Business MaiEing Address: <br />State Zip <br />Phone`, ���..� 1=�,�t � �`,�';� =� Email: ��� ,t�°� �'���j �:t��-�,°�t � � '�:. r����� �;�� i�:�« �°.l".. �°��Y� <br />Cate o Description Uni�s Quan�it Rafie 7otal <br />Administrafiian Adrninistration / management Hours <br />Labar CCTV �nspection Hours _T���� <br />8WV Irtstatl Hours <br />Pipe repiacement Hour� <br />Surface restoration Haurs <br />Sife cleanup Hours <br />Downspouts I clrainage imp. Hours <br />Materials Backwater valve Per Unif -�- ; <br />Grinder pump Per Unit � <br />Side sewer pipe {up to 8 feet) Feet b� cr �" <br />Imported Backfill Yards <br />Surface Restoration Materials Lump <br />to soil, rass seed, concrefe, efic. sum � <br />Gbver {irrigatian box or laad bearing Per Unit <br />cover <br />Renfials Specify equipment , Nour <br />�-. � — <br />Fees Disposal #ees by ifern Yards <br />Qelivery fees if not �overed by labar <br />Eligif�fe Total . i ' E _ . � $ . <br />Other Costs Gosts not associated with BUU�, and <br />r�ot eEigibie for rebate detaii belaw <br />�'i'' �,�� f��,�r-�..�.� �pw:�;.���� ���`r�� <br />a <br />o-������� � :�� . <br />��-.�: � .�a�-�� i,� p �.+,� ; � z <br />1'neligible TotaE � � � -<� � ��;�o�, , � �, <br />7ota1 � <br />Reuised 9iO3/20�4 <br />� <br />