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�. , � . .. i . • � • . <br />�, . <br />.� : � i �` ►� i• <br />Please use tl�is lnvoice Cost Breakdown as a tempiate fc�r ir��oiees submi#ted as part of the Bacicwater <br />Prevention Device rebate program. Either ihis form or your own invoice form with the follawing line items can <br />be submitted. This allows yau to invoice your client according to your existing biliing template while al�owing <br />city staff to identify how cosis eligible for the Backwater Arevention Device Rebate were accrued. <br />Ondy ►abar and materials directly related to the insfallation and funcfian of a backwafer prevenfion <br />device are eligible for Ci#y rebafe and fh�refore should be included on the upper half of this form. <br />Additiona! costs may be added to bottom of the form. <br />j�:,�'! ��,�'`�C". <br />Business Name:,�,v71N� �c�.�"l. ,�'�.��'�{��'� License Number: ��.'���"'��'� <br />Business Mailing Address: c���-i�� (�,C;z �"�l�i �� �--- �d.%' ��7� 1.�l� � U �t�� <br />Cify State Zip <br />Phone_�..�`�ICS�',��;-�: Emaii:��a�'>�t�,c,�r�� �� �.���'!� �i���;��r2'i"' C��37'1 <br />Cate o Descri tion Units Quanti Rate Total <br />Administration Administration / management Hou�s <br />L,abor CCN lnspection Hours 't ; <br />BWV Instail Hours <br />Pipe repfacement 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 S feet) Feet �� `� <br />lmported BacEcfill Yards <br />5urface Restoratian Materia(s Lump <br />to soil, rass seed, concrete, eic. sum �° <br />Cover (irrigation box or foad bearing Per Unit �� <br />cover � c3- <br />Rentals Specify equipment T Hour <br />".�'C✓ c-�,�. , .--ry - �.� <br />�ees Disposal fees by item Yerds <br />Delivery fees iF nat covered by tabor <br />Eti ihle Tota1 " cti-=� $ <br />Ott�er Costs ��s#s nflt associated with BWD, and <br />not e!i ible for rebate deiail below <br />b <br />� <br />IneEigible Total l,ub.sli! $ <br />Total _____ __...`-- 6 $ �-- -�,�-= <br />Revised 9/03/2014 <br />