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i <br /> � � � �� �c�o <br /> Please use this invoice Cost Breakdown as a temptate for invc�ices submitted as part ofi the Backwater <br /> Preventian Device rebate program. Either this farm or your own invoice fcrrm with fihe following line items can <br /> k�e submifted. This allows you to invoice your ciienf according to your existing billing template whil� allowing <br /> city staff to identify how costs eligible for the Backwater Prevention Device Rebate were accrued. <br /> Only labor and maferials direc�ly related to t}�e insfallafion and funcfion of a backwater prever�tran <br /> device are eligible for City r�bafe and#herefore should be included on the upper�half of tf�is fnrm. <br /> Additional costs may be added fo botfom of the forrrr. <br /> ��,���(,,,��� � ��"� <br /> Business Name:� � � "�..rf"�� c� License Number: (��;��"7c1 <br /> � �. <br /> Business Mailing Address: %- �-�c. L.C'��'""�1/l ��-- �r 1c�,,r'��fi� 1 1r� G?'�a���t�!�.�a µ <br /> City State Zip <br /> Phone:'��.,��C� "����'� Email:�'.� �c.:��,�"�r �,+���.�' �� ��� �r-��'��d.t�'� +C���"'r? <br /> Cate o � Descri tian Units Quanti Rate To#at € <br /> �dmini�tration Administraticsn/managernent Hours �' <br /> �.abc�r CCTV Inspection Hours � <br /> E'. <br /> BWV Install Hours <br /> Pipe rep(acemen� � Hours i. <br /> SurFace restacatian Hours � � <br /> Site cleanup Nours <br /> downspouts/dr�inage imp_ Nours <br /> Materials Backwater valve Fer Unit <br /> Grinder pump Per Unit <br /> Side sewer pipe(up to 8 feet) Feet i t ; <br /> � <br /> Imported Backfill Yards �' <br /> Surf'ace Restoration Mafierials Lump = <br /> to soi1, rass seed, concrete,ekc. sum � �vp v(� ` <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 /> � <br /> r <br /> Delivery fees if not�overed by iabar s <br /> � <br /> €, <br /> �ti ihle i"otal < � <br /> Other costs Costs not associ�ted with BWD, and <br /> not eli ible for rebate detai!below <br /> t':� :: t�% ti:��'a c:.��t#`�c e i--�.°" <br /> "� .�t f'r'' ..,:^,f � �r'�„� .Y.� <br /> .. . ..... . �✓�:'t.:7t�.y,,•y. .. . . . ....... . '; <br /> ?3s't�'i.dr £A.»�d.�:�g�.t <br /> �n0�tglrl�@�TOta� "? � � �'` � <br /> Toial � <br /> � <br /> � <br /> , <br /> � Revisad 9/03/24�4 i� <br />