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F <br /> i <br /> 4k77 BACKWATER PREVENTION PROGRAM <br /> - <br /> INVOICE COST BREAKDOWN <br /> Please use this Invoice Cost Breakdown as a template for invoices submitted as part of the Backwater <br /> Prevention Device rebate program. Either this form or your own invoice form with the following line items can <br /> be submitted. This allows you to invoice your client according to your existing billing template while allowing <br /> city staff to identify how costs eligible for the Backwater Prevention Device Rebate were accrued. <br /> 3 <br /> Only labor and materials directly related to the installation and function of a backwater prevention <br /> device are eligible for City rebate and therefore should be included on the upper half of this form. <br /> Additional costs may be added to bottom of the form. <br /> Business Name:- ):Qi f;�?t-� - License Number: <br /> Business Mailing Address: L CLe n 69,' J f,•�P 7" !(� O'Rjn'� <br /> �" /�. <br /> City State Zip <br /> Phone: 1, y �, 'k Email:f )tl/YlY1'i'<<rri ':3 i�r �'C ij� � <br /> Category Description Units Quantity Rate Total <br /> Administration Administration!management Hours - <br /> Labor CCN Inspection Hours <br /> BWV Install Hours <br /> Pipe replacement Hours <br /> Surface restoration Hours <br /> Site cleanup Hours <br /> Downspouts/drainage imp. Hours <br /> Materials Backwater valve Per Unit <br /> Grinder pump Per Unit <br /> Side sewer pipe (up to 8 feet) Feet <br /> Imported Backfill Yards <br /> Surface Restoration Materials Lump <br /> (top soil, grass seed, concrete, etc. sum D <br /> Cover(irrigation box or load bearing Per Unit <br /> cover) <br /> Rentals Specify equipment Hour <br /> 3 <br /> Fees Disposal fees by item Yards <br /> Delivery fees if not covered by Iabor i <br /> -A- <br /> Eligible Total 4KN $ <br /> Other Costs Costs not associated with BWD, and _ <br /> not eligible for rebate detail below <br /> Ineligible Total $ <br /> Total $ <br /> Revised 9/03/2014 <br />