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BACKWATER PREVENTIONPROGRAM <br /> INVOICE COST BREAKDOWNPlease 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 /> I <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:: 7 �(} -`7;r^�c License Number: d—'6 , l�3 <br /> Business Mailing Address: i � ' f �l/l i - Et <br /> City r i State Zip <br /> Phone: 1 � � ' Email: ' �,t"+11`'(ll+'ri,c4r9_11,cJ78&�•1�,ad &'r';j"" a�+ole'd yC )D, 7 <br /> 7.T—s� <br /> a <br /> Category Description Units Quantity Rate Total <br /> Administration Administration/management Hours_ <br /> Labor CCTV 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 /> to soil, rass seed, concrete, etc. sum D <br /> Cover(irrigation box or load bearing Per Unit <br /> cover) <br /> Rentals Specify equipment Hour <br /> Fees Disposal fees by item Yards <br /> Delivery fees if not covered by labor <br /> Eligible Total <br /> Other Costs Costs not associate 6with BWD, and <br /> not eli ible for rebate detail below <br /> We, 1z ct, s 9 <br /> l <br /> Ineligible Total $ 3 A L <br /> Total 1 $ ,L-5 ` <br /> Revised 910312014 <br />