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A ; ��' :�, "� � ,A �E A '!+ �- <br />— <br />x �' .- <br />�', s s;.. < �.-. �<_, _. ,...; , ;.. �; � , � <br />� � : � ,� " �. �.. . �._, �' .� '�� � <br />P{ease uss this tnvoice Cost Breakdown as a femplate fqr invoices submitted as part of the Backwater <br />Pravention Device rebate program. Either this fiarm or your own invoice farm with the following line items can <br />be submitfed. This allows you to invoice your clienf accarding to your existing bifling temp(ate while allowing <br />city staff ta identify how costs eligible for the Backwater Prevention Device Rebate were accrued. <br />Only labor and materials directly related to fhe insfaliafion and function of a backwater preventron <br />device are eligible for Ciiy rebate and fherefore should be included on the upper half of this form. <br />Additiona! costs may be added to bottom of �he form. <br />�`�-�:� �'���-'�--, <br />.�-. <br />8usiness Name:�� �1�'� � i e:.� �� 4�'^�r'-�� "F�� rr�`,��' License Number: (`-,���;�� �� <br />" b <br />� � <br />Business Mai[ing Address: �G�•�� (,�`<.r— %l'i ����--- ����?.�'�� �i i-�`./f-� � �.�L� <br />City State Zip <br />Phone:;�:� �:-�IL �',�� ���� � _� Email:�.� n 1 ; ._� r �-� �^�,,. :�r �; � ,� �� _� x� , �'e> <br />Cate o Descri tion Units Quantit {2ate Total <br />Administratian Administration / management Hours <br />Labor GGTV lnspection Hours ,, � <br />BWV Install Hours <br />Pipe replacement Hours <br />Surfiace restorafion Haurs <br />Site cleanup Hours <br />Downspouts! drainage imp. Hours <br />Mafierials Backwater valve Per Unit -� � <br />Grinder pump Per Unit <br />Side sewer pipe (up ta 8 feet) Feet �i . tt �,.-��" <br />Imported Backfill Yards <br />Surface Restoration Materials Lump <br />top soil, rass seed, concrete, etc. sum �(� <br />Cover (irrigatian box or load bearing Per Unit <br />c�ver ��` <br />Rentals Specify equipment Hour <br />— _ � - -- r`7 �"C.� <br />✓ <br />Fees Disposal fees by item Yards p�-- <br />Deiivery fees if not covereci by labor <br />Efi ible io�al �, . C� - g, <br />Other Costs Gasts nat associated with BWQ, and <br />nat eligible fior rebate detail below <br />� � � � ��� <br />� <br />d � �.�c <br />ib <br />lneligible Tatal $ <br />Total $ <br />Revisecl9/03/2014 <br />