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BACKWATER PREVENTION PROGRAM <br /> INVOICE COST� BREAKDOWN <br /> Please use Ihis Irnoice Cost Breakdown as 2 template tor invo�ces submitted as part nf the Backwater <br /> Prevention Device rebate proqram. Eilher this torm or your ovm invoice form w�th the tollowing hne i�ems can <br /> be submitted This allows you to invo�ce your cGenl according to your exishng bdl�ny template whd�: allo�r��ng <br /> city staft tn identdy how costs eligible for the Backwater Prevent�on Device F2ebate were accrued. <br /> Only labor and materlals directly relafed to the installation and/uncfiun of a backwater prevenfion <br /> device are eligible /or City rebafe and thera/ore should ba included on the uppur hall of this /orm. <br /> AddiGonal costs may bc addod fo hotfom nl fhe Iorm <br /> Business Name /Q'�_ �I Llti� W(Y� L��._ Licens� Numher __�P__('(`19° �/1��� <br /> Business Maihng Addres5 __ ����_ f.5�<_✓(r21'!_t� _.��-����7-��__ /,l�.d � <br /> CVy SI le Z�p <br /> Phone. �7.� _ yB aI-��'' �_ Finail f�J ���n� l�//�, l CC��/��C/li�/9tl- �(�-r� <br /> -- — — `J -- • -—- - <br /> Category_ jDescrlption ___ � Unils Ouantily ; Rale . Total <br /> Administration I Admm�stret�on /managemenl I Hours <br /> -- I - — -- �- -- —— <br /> Labor CCTV Inspect�on Hours �C O <br /> .— . — 1. --- .._ ..—._ _—. ----------- <br /> � BVJV Install Hours � __� / 2 S'U <br /> -- - ---- `- -- .. _- --- �---- —..__. . . . .. _ _� <br /> . Rpe, replacement Hours � � � fj—�_ <br /> _ ... . _.�. ..__ _-_ ._-- - � -�� � -- __ , <br /> � Surtau:restorat�on Hours ! 4 / ' <br /> - --. .- -- - _-- -- - - f �--- � - <br /> Silc cl�anup Hours , j . <br /> i _ . . . _ . . — -�- - ' 1 - - <br /> Uotvnspouts/drain agr imp. Hours �� <br /> . — .. . .- — - -- ��-- —. . »-- - - — - - � --�- <br /> Mate�ials Backwiter valve Prr Und � � � �..-- - <br /> -- --- - --- � <br /> GnnAer pwnp Pcr Unit ! ' <br /> t - ----- - - -- - � - -- -- .— . _ - —' i �- ----- � <br /> Side sewcr pipe (up la 8 teel) Feel � ' <br /> �_ . _ . __. . —� -- -- - --- - + -- ' - -- ----- <br /> - -- -- Impnrted Rarhlill Yerds ' �. I <br /> --- ! -- - �� -- —.. <br /> Suriace Hestoraliun Ma�enals� Lump ' ( � ` <br /> _ . _ _(In�� soil. grass sced. conr.rete. r.tc) sum _i _. _J.. __-- ---- <br /> Cover(irriqolion hox ui load l�eming Per Unil � I � � <br /> cover) <br /> � Rentals Speutyr.qwpmr.nt Hour � ! � <br /> -- � -- - � - . .__. . . ---_ . . - � -------- � <br /> - - - - - <br /> •_- --- -- - � i <br /> Fecs Dispos fr e;by ilFm Y+uds , i <br /> . --- - . .__. , --- � �--- <br /> , � .. �.'"5 � � . . �a ��.— . � <br /> ' Dulivi y fces i(nol �.ovcred by� laboi � <br /> , ._ _ . _ _ ... --�---� --- <br /> EG Iblc Tolal � $ ��Sf <br /> � Other Costs Cosls not assot:iatr,d with ON/D,und <br /> . not eligiblc lur rrbate tdetail below) - --- . - . - <br /> , . --�- � -- �- -- _ _. . — - - <br /> I . _ .. --- _—. .. _-- - --- - ----- �-- <br /> !--- - _. ._.--- - — . ._ . __—_.� . . _ _ _. - -- --_ .. - -- <br /> � <br /> Ineligible ToWI -- - -- ---- - — - $ ��� <br /> Total i — � <br /> --- -- - . .__ —. $.�L - . <br /> �-x <br /> I <br /> Revised 9I031"1014 ' <br /> r <br /> / <br />