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� s � 1 . .. : . -� . �� � <br />>� � � <br />�� � ' :� � � ' � i !': � F. <br />F..� � <br />Piease use this {nvoice Cost Breakdawn as a template for invoices submitted as part af the Backwater <br />Prevention Device rebate prograrn. Either this form or your own invoice form with the follawing fine items can <br />be submitted. This allows you to invoice your client according to your existing billing template while allowing <br />city stafFto identify how costs eligible for the Backwater Prevention Device Rebate were accrued. <br />Only labor ar�d ma#erials directly related to the rnsfallafion and function of a backwater preventian <br />device are eligi6/e for Gity rebafe and therefore should be inc(uded on the upper haff of this form. <br />Additional cosfs may be added fo boitom of the form. <br />� �,���.c �'ti . �'�'�-' &.. �-� -� ...� .� <br />Business Narne;,r°��,�"1,� ��-� ����-s �v=a(���.t..��=-�-��1''��'� License Number. t>�;-°�;��.�r _ <br />. � <br />Susiness Mailing Address: ��ilt.�-(�.A � ��cl� �` �:...- �i.fr'>>iC`�`7 ( �Jr'-� � �:=�tt ��� <br />City State Zip <br />Phone:.� s��:.' =x��v '-���'�. Email;�'��a�"�-��1r-:���'�'a�`ir�-z.rt ��J��:..�r�r�.�� =����,�:,tZ��"' C�7�� <br />Cate o Descri tion Uni4s Quanti Rat� Total <br />Administration Rdmihistratiqn ! management Hours <br />Labor CC7V inspection Hours <br />BWV lnstafl Hours ' <br />Pipe replacement Hours <br />Surface restoratio� Hours w� C� � <br />Site� c)eanup Hours <br />Downspoufs / drainage imp. Hours <br />Maieria[s Backwater vafve Per Unit �, ;�� <br />Grinder pump Per Unit <br />Side sewe� pipe (up to 8 feet) FBet e� -,°' ,f-�'� <br />Imported Backfil( Yards <br />Surface Restoration Materials Lump <br />to soil, rass seed, concrete, efic. sum �� <br />Cover (irrigation box or load bearing Per Unit <br />cover �- <br />Rentals Specify equipment Hour <br />— - ��� <br />Fees Disposal fees by item Yards �- ��-� <br />Delivery fees if not covered by labar <br />Eli ibte TOtal ; v� .< z/. <br />lJther Costs �Q��s not associated with BWD, and <br />not eIi ibfe for rebate detail below <br />�. �, �� ��;�s�.����� a���.,�,�.� �,���., � <br />�..d.;,,,� -- �.,�,�,, . <br />. » �"�`�'4� . .- . ��.1�+-, L.; � i � � <br />Ineligibte Total `''$ ��`� <br />Tota1 � � - �1 • <br />Revised 9/�3/2014 <br />