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� <br /> � �� H� ��� � �� ���� ', <br /> � � � � � <br /> � <br /> Please use tFiis invoice Cost Breakdown as a tempiate for invoices submitted as parE of the Backwater <br /> Prevention Device rebate program. Either this form or your awn inv�ice form with the following line items can <br /> be stabmifted. This allows you fo invoice your client according to your existing f�iffing template while al(owing <br /> city staff to identify how costs eligible for the Bacicwater Prevention pevice Rebate were accrued. <br /> Only labor and maferials directly related fo the installation and functian af a 6ackwater prevention <br /> device are eligible for City rebate and fherefore shouid be included on th� upper hatf of t�ls form. ; <br /> Additiona!costs may be added to bottom of fhe form. <br /> ,r^��� �J`��-,��,:t.''�..�� t <br /> (�,��L�.�>�'N ( <br /> Business Name:��'���q���r2t--ti���r}� �r_�-..z}-%7�License Number: (�i�:����;� _ <br /> Business MailingAddress: v�lt�"�-�� L-�"��'"f�� �`,���'-,_ ���1'�`�'°'� (-�'��+'�� ���=�t��� <br /> City State Zip ; <br /> Phone :��`�;f`�JC,� �,���=� Email:�.,��r��1�.xr����cr���__��T���:.�.�fi w�����':c:,J �- '" � i <br /> r:r�'s i-c'i ai''f <br /> C�te a Descri tion Units Quan#i# Rate Tota1 <br /> Administration Administration/management Hours __ <br /> Labor CCTV Inspection Hours ' <br /> 6WV Insta(i Nours � <br /> � <br /> Pipe replacement Hours � <br /> ,. <br /> Surface restoration Hours <br /> Site cleanup Hours <br /> Downspauts/drainage imp. Hours <br /> Materials Backwafer valve Per Unit - � <br /> Grinder pump Per Unit <br /> Side sewer pipe(up to 8 feet) Feet y ��' <br /> Imported Backfill Yards <br /> Surface Restoration Materials Lump <br /> to soi(, rass seed, concrete, etc. sum � "� <br /> Cover(irrigation box or load bearing Per Unit Q <br /> cover <br /> _— � <br /> Ren4als Specify equipment Hour _ <br /> . <br /> � <br /> � _ ._..__ —, . <br /> Fees Disposal fees by ifem Yards � <br /> Delivery fees if not covered by labor <br /> Eligible Totat � ,�,�C. . � � <br /> Ofher Gasts Casts not assaciated wifh BWD, and = <br /> nof eli ible for rebate detail below <br /> � �� � � <br /> �3 K� <br /> � <br /> — -------- f � � <br /> -----_.._._. g . �r.� :�' <br /> � <br /> ineligibie Total $ �r"� �� <br /> Total $_.,� (�� _ <br /> Revised 9I03/2094 <br />