Laserfiche WebLink
� � � : �t � �?: :�% /i, <br />�"' �. � T'>. '� y,�° 'f �; i �� <br />�,�. � �: � � # �. V ' � � � 1; `�: i <br />£ -s � � ;+�§ - ; <br />� � <br />Please use this invoice Cast Breakdawn as a temp[ate for invoic�s suE�mitted as part af the 6ackwater <br />Pr�ventian Device rebate pro�ram. Either this form car your owrt invoice form with the foliowing {ine items can <br />be submitted. This allows you to invoice your cfient according to yaur exisiing bii(ing template while altowing <br />ci#y staff to identify how costs eligible for the Bacltwater Preventic�n De�ice Rebate were accrued. <br />Only Iabor and rnaferials directly related fo the instaltafior� and funcfion ofa backwater prevenfiorr <br />device are eligible for Ciiy reba�e and there�ore shauLd be included on the upper half ot' t%is form. <br />Additional costs may be added to bottom of �he form. ��� <br />t��'��� f '�-� ��'.` s,� <br />Business Name:�t�����r�t�� �-�f3��._!•�`-�'' �.r�''�� License Number. _ ' '�'� <br />, . �� <br />- - . �. �... _ <br />Business Mailing Address: <br />5tate Z�P <br />-� � � � � ':�, Email:��:ii"����',t��.�`��J�i��r�~ar� T ��� r�s��,� ��a�a� �N;-�2�.� , C'"�5�'3'� <br />Phone:,::� �Jv .���� � <br />Revised 9/03/2014 <br />