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� r .j " y ' rr ■ ri. a � ;^' r . � . ' wE; !; <br />s <br />�� � � : r :'" a � � <br />� . . a �., e< <br />Pleas� use this Invoice Cas# Brea�down as a templ�te #�r invoices submitted as part of the Backwa��r <br />Prev�ntion �e�ice rebate program. Either this fc�rrr� or your own invoice form with the fallowing (ine items can <br />be s�tbrrritted. This al[aws you to invoice yaur client `acc�rding % your existing billing template while allowing <br />cify staff tv identify hovu costs eligible for ths Backwater Prev�;ntion Device Rebate were accrued. <br />IDnl,y labor �nd maierial� directty relaied fo th� instal/aiinn and function of a backwa�Fer prevenfian <br />devic� ar� ��igoble for Ci#y rebafe and therefore should be inc/uded on ihe upper hatf ot th�s form. <br />Addi�ianal cQsts may b� added to boitom af the form. <br />Busin�ss Nam�� �i����-',�`"J��,�� ��,,,�. License Numk�er: � t;>� ��,ifi%'r�� <br />G�usiness M�iling Address: ,���t � <br />Phone: �`��.." � �"-��'�%G � <br />AsiminOstratian Administration / rna <br />L���r CCN Inspection <br />�WV (nstall <br />Pipe repiacement <br />Surface restoratian <br />Site cieanup <br />Downspouts / drai�age imp. <br />Ma#eriat� �ackwatsr valve <br />Grinder pump <br />Side sewer pipe (up to 8 feef) <br />Imported Backfill <br />Surfaee ReStoration Materials <br />to soil, rass seed, concrete, e�c.} <br />Gauer {irriqation bax or load bearing <br />a <br />fees by item <br />fees if not cover�d h� <br />���� �p��� Gosts not assooiated with BWD, �n <br />ngt eliqible far febate (detail belcaw <br />Revised 9/a�/2D�1�R <br />Unizs � <br />Nours <br />Hours <br />Nours <br />Hnurs <br />Hours <br />Hoiars <br />Hours <br />Per Unit <br />Per Unit <br />Feet <br />Yards <br />tump <br />sum <br />Per unEt <br />Haur <br />Yards <br />� <br />e <br />� <br />� <br />��� <br />% � �? - <br />� <br />� <br />$ �C,���i�< <br />� <br />--) '�_�."�'_'. <br />