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�� �� � ' <br /> � '�' � T `�-��-� ���s�`�c�. <br /> Ple�se u�e this �nvnrcP Cost Breakdown as a tet-np[ate for invaices submiffed as part of fhe Backwater <br /> Preven�ian Device rebate program. �ither this form or your awn invaice form with the following line items can <br /> be submitfed. 7his alloUrs you to invoice yaur clienf according to your existing bilfing template while allawing <br /> city staff to identiiy how costs eligible for the Bac{cwater Prevention Device Rebate were accrued. <br /> Only labor and maferials direct/y relafed fio the instal/atron and fursctfan af a f�ackvvater prevention <br /> device are eligi�le for Cify rebate and�herefore should be included an the upper half of this form. <br /> Additional costs rnay be added to bottom of the form. <br /> Business Name: t�,�'� License Number: ���%__ �'7�(�� ' <br /> Business Mailing Address: �.�zr'�_`�l��' /'�wr. � ��t�<��`" �l�__ ���7� <br /> City State Zip ' <br /> Phone: Email: __ <br /> Cafe o Descri tion Units (�uanti Rate 1"otal , <br /> Adminis�ra�ian Administration/management Hours <br /> Labor CCTV lnspection Hours �(,� <br /> B1N1/lnstall Hours ��.� <br /> PPpe repfacement � Hours <br /> SurFace rssfo�ation Hours <br /> Site cleanup Naurs (,� � <br /> __.....__— <br /> Dov��nspouts J drainage imp. Hours <br /> Materials Backwater valve Per Unit ��- , <br /> Grinder pump Per Unit <br /> Side s2wer pipe (up to 8 feet) Feet ; <br /> Imported Backfill Yards _ <br /> Surface Restorafion MaferiaEs Lump <br /> top soil, grass seed, concrefe, etc. sum <br /> Cover(irrigation box or load bearing Per Unit <br /> cover) � <br /> Renfals Specify equipment Hour <br /> _........._ ; <br /> Fees Disposal fees by item Yards <br /> _____- <br /> Delie�ery fees if not covered by labor <br /> � <br /> ' EIi ibie Total � <br /> Other Costs Costs not assaciated�vith BWd,and I <br /> nof eligible for rebafe(defail be(ow � <br /> -- t� — <br /> -c. <br /> ineligible Tatal � ', <br /> Tatal � <br /> ������ <br /> Revised 9/03/2014 j <br />