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BACKWATER PREVENTION <br /> OST 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 /> 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.Amet-i ce in w(} ,r 2• License Number: f:> 4 <br /> Business Mailing Address: te--x 1 kri t �fP�' ' 7 (.�' ' c) <br /> City State Zip <br /> Phone:, -1:Qclb --, >'-1 Email:(',a . ")a4 cic r n, :� r;,.�' i '.1rn C 7 <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 y,, <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 C' <br /> Imported Backfill Yards <br /> Surface Restoration Materials Lump <br /> top soil, grass seed, concrete,etc. sum 13 C� <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 $ de <br /> Other Costs Costs not associated with BWD, and <br /> not eligible for rebate detail below <br /> Ineligible Total —- $ <br /> Tota I <br /> Revised 9103/2014 <br />