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� �° j � � �i"> �� � ` � $ �� � � :!� `� <br />� �;. '•.,y � > 3 . . , � . <br />t �., <br />� :� �� � x r.. ��> � <br />Pleasa use fhis fnvoice Cost Breakciawn as a tetnplate fpr invoices subm►tted as part of the Backwater <br />Prevention Device rebate prograrn_ Either this form or your owr� invoice farm wifih the fr�ilowing Iine items can <br />be submitied. This ailows you to invc�ice your client according to yaur existing �il[ing terriplate while al[owing <br />city sta�f i;o identify how cosis eligible for the Backwater Prev�ntion Device Rebate were accrued, <br />Only labor and materials di,rectly related tv the installation and funcfion of a backwater preventian <br />d'evice are etigihte fi�r Cify rebate and fherefore should be inciuded on the upper half af this fa�rrr�. <br />Additiana� costs may be added to battom of the form. <br />�,�,��" _' �,.J� ,� -� .� <br />Business Name: � �Y -, -<. t� , � `'� � <br />.�"��, ��i}�fdC:.::� ; �iC'�i? License Number: 1.�.'�'..�.-`�^`�'"r�'��� <br />T <br />Business Mailing Address: �-��i%�-�.% �=��� __._��� �����7 l•t' �r� ��''���{��� <br />City S#ate Zip <br />Plione:�..�`�;, J,��C3 � �'�`� � Email:�� � �� �'v f-� j �r-z�'t � ���i�;.�,��,� �� ���' J�,�.-r �'�'"", � t�3 <br />C�te o Description Llnits Quanti Rate Total <br />Administretion Administrat[on / management Hours <br />Labor CGTit Inspection Hours � <br />BV1/V I[iSt3ll :NOUrS <br />Pipe replacement Hours <br />5urface restoratian Haurs (,X.,� <br />Site cieanup Hrsurs <br />Downspouts / drainage imp. Nours <br />Materials Backwater valve Per Unif �,. <br />Grinder pump Per Unit <br />Side sewer pipe �up to S feet} Fest L� � ' C% �= <br />Impo�ted Bacicfiil Yards <br />Surface Restoration Maierials Lurrtp <br />to soil, rass seed, cancrete, etc. sum "� L� <br />Caver (irrigation bax or load laearing Per Unit <br />cover �--- �. �'" <br />Renials Specify equipment Hour <br />,� - - _ . ,�,, ..._ . <br />, � �: <br />� <br />Fees Qisposal fees by item Yards � '' ;. <br />Delivery fees if not covered by lab�r <br />Eligibie To�at ",�" M ,. f -, .., � r� 1` - t <br />Other Cnsts Costs not associated wifF� BWD, and <br />not eli ible for rebate detai{ below <br />�,., t� <br />�. �. tr°#��' <br />i� �r <br />Ineligibfe Total � � ! � <br />Tofiai � � � � , <br />Revised 9I03/20�4 <br />