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` �-:. � Y`, � T � i <br />�!� � `� � '�' �r 3�' � . "F <br />� � �.� �.y � � � <br />� r� �, � ��h �" '�� � <br />Pfease use #his lnvoice Cost Breakdown as a#emplate for invoices submitted as part of the Backwater <br />Preverttion Device rebate prograrn. 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 bilfing template while allowing <br />city staff to identify how costs eligible for fha Backwater Prevention Device Rebate were accrued. <br />Only labor and materials directly relat�d to the installation and function of a backwater prevenfion <br />device are eligible for City rebafe and therefore should be included �n fhe upper half of this form. <br />Additiorra! cosis may be addeo' to 6otfom of the form. <br />�' � - ..;�;�- ,�'.�C::..; <br />U��"�� � �' <br />Business Name:��•� =� �' <�� 1r �i=� , G.��:- ;r, c-; License Number: (`��a;~�����"� <br />;� C f' {-_--:� ) r�-i 'Zi' 1 <br />���-= <br />Business Mailing Rddress: �1�%C-�1 L,.a'':� j`�� �r� y� V� .� J✓� fa�?��� j` �� i�";1 ���`�t1,� <br />� City State Zip <br />Phone:��, s:�.L��'���'�,-� EmaiL•�.�i`�� �.��a,��f r��{���r: .! "�:,s�t���i �� irz.� �:��-r �'� t��c%�I <br />---c r <br />Cafie o Descri tion Units Quanti Rate Total <br />Administration Administration I management Hours <br />Labor CCTV Inspection Nours � <br />, <br />BWV lnstall Hours <br />Pipe replacement Hours <br />Surface resforation Hours <br />Site cleanup Hours <br />Downspouts / drainage imp. Hours <br />Materials Backwater valve Per Unit '� -;� E._ � - <br />Grinder pump Per Unit <br />Side sewer pipe (up to 8 feet) Feet -� � �e <br />Imported Backfill Yards <br />SurFace Restoration Materials Lump <br />to soil, rass seed, concrete, etc. sum ,� L� <br />Cover (irrigation box or load bearing Per Unit <br />cover _ � � � � <br />Rentals 5pecify equipment Hour <br />..,.r �� ,.� <br />Fees Disposal #ces by item Yards � <br />Delivery fees if not covered by lahor <br />�figible Total � ��G,� -, "� $ � .�� � <br />Ofiher Costs Costs not associated with BWD, and <br />not eii ible #or rebate detail below <br />_ C7 i� � �.. <br />, <br />Ineligible ?otal f � � <br />Tatai �.� � $ � <br />Revised 9103/2D94 <br />