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g� g � ;. �w: a.- � �� 3! 3~ '*' �� <br />. � ,. !':: <br />� � � � $ � � � `:!� �' t' ` � � { <br />, . <br />�. , <br />���� . b ; <br />� . <br />, <br />. <br />a e�� F� . - <br />� ��� . r��,,, � �,� � , _ <br />Pieas� use fhis Invoice Gost Breakdown as a t�mplate for invaices submii�ed as par� of the Backwater <br />Prevention Device rebate program. Eiti�er this form or yaur own invoice form with the foliawing Iine i#ems can <br />be submitted, This alfows you fo invaics your cfient accarding ta your existing bifling template while affowing <br />e�ty staff to identify how costs eligible for the Sackwat�r Pr�ventic�n Device R�bate were accrued. <br />Onl,y labor and maf�rials direcfly related to the insfallafion and functran of a backwater preventian <br />device are eligible for Ciiy rebate and therefore shauld be inciuded on the upper hal�' of fhi� %rm. <br />Addif+ona( costs may be added to bottom of the form. <br />�� �`��:��� �',�� �- ti � <br />Business Name;.r'-��r�`1�-'��� r�. a f�4 �±;�1}�7.�.,�-�`�+t'�� License Number: ���.~-�� �"'��i <br />_ ,-. _ <br />Business Mailing Address: r%�1���'-� L�-'� ��� � �-� �- �--'�" � � - �' �-"" _' " �'�". " <br />Cifiy 5tate Z�p <br />�"� "` r "�� ti .�. • �,;, ,�#„ EI7l8I I . � � . I I '� r'a'` ,(r"� ;`-y : ; �.- � r� . ' I � - �.c K �'•� �' .� <br />Phone: ��� � !� -�`��°� - <br />Revised 9/03/20fi4 <br />