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i <br /> BACKWATER PREVEYVTIOIV PROGRAM � <br /> � <br /> INVOICE COST BREAKDOWN ' <br /> , <br /> ; <br /> Pleaso use this Invoice Cosl Breakdown as a template tor invoices submilted as part oi the Rackv:ator I <br /> Prevenlion Device rebate program. Either this form or your own invoice form with the following linr, items can <br /> be suhmitted. This allows you to invoice your dient accordin,y lo your exisling billing template while allowing <br /> cily slaff to ioimtify how r.osis eligihle for thr. Rar.kwater Prevention Devicce Rebale �vere accrued � <br /> Only labor and materials directly relatr.d to the insfallafion and funcfion af a backwater prevenfion � <br /> device are elir�ible(or Ciry rebate and ttrerelore should be included on the upper hal►of thls form. ; <br /> Flddrlional costs may be addr.d to bottom o/fhu Io�m �` <br /> c at'� �.L�'' i <br /> i��� �.J �� V <br /> �usiness Name:�yryl('�'![ceI] .<�Q�l�.•�:-i LC'1(' Luxnso Number: ___��J��:a _ __. . <br /> HI151f1P.55M811111� A(Jf�fCSS: �(G_GtL�_ L.C;�1���__ilV�"• _����c'f���_._. LL�,�;_ . .U<�:���3 _._ ' <br /> Cily Stalr, 7_ip <br /> ('hone .�';�()._",a�.`S.i� ---- . Email.(��4JGi117;:C�;�t���i�_[.!/It} �.d��L{'L• �'C1yJ� <br /> , <br /> � --- - ...-. _ �. ._ .._ -�� Unils quantit --Ratc ' .. . - Total .. ... _ �' <br /> Cate o Deser�tion _ ._ .__ - � - ---Y. - -- --�- .. . <br /> __8 rY .-_ <br /> �Administrelion Adminishatmn l m;�nar�ment �����- ' <br /> -- = --- __ <br /> - <br /> -- <br /> LLabor CCTVInsperlion Iinur., I ?j,s� �� ___ <br /> --- Hours <br /> �_ t�wv i�zr,n -- - _ - - --- <br /> --- - — _ __ _ <br /> i Pip��eplacement 1lauis__ _ _ _ _ , <br /> �--- - - ___ _ �� <br /> ____._ _- Smi.icc rr.s�oiabnn Hrnus T���1.-- - L'^�� <br /> � �---- �� -- Siter.leanup Hnurs � �� -- . <br /> � _ _ . .Downspouls/diaioap�imP. Hours � _ __� _ � �---- - � <br /> ..- -� -- ---- - <br /> - ------- _. _ -� <br /> � M�ferials Aac hw•der v ilv� Pnr Unil `'���1�'� !{�'f'f J� . .��5. <br /> ._. _ . .. __ . _._ - -- ----- � <br /> ..— - Gtmder pump Pei Unil ' . <br /> � ---- �— �-- �--_�-- �--�.__. <br /> -- - -- -- — -- - J <br /> Sid�.sewerpipe(up_to8lcet) _ Fer.l �._��.�(o�� r211]��d� - - .> - <br /> hn�orted Da�.kfiil Y�{rds <br /> - -- -- - <br /> ._ ._. . .-. .Surfacc Rr.,toration Milr.nnls_ .-- I ump. ,� _� � . <br /> i _ (�oP soil, gr�ss seed, �onr,reie, etc.)_ sum _ � _- _ �'(_. _- - �x�.- - <br /> � ��� Cover(uri�ahon bnx or loid hearin9 Per Unit � <br /> � _ � .� /�a . <br /> cover) _ - -- ---- - - <br /> _ _ Haur <br /> i-Rentals Sper.if er ui ment ..-- -_ _-- _ - � -- . __ ._ -- � <br /> �--- _ Y I P - - - - <br /> i _ T/1cr;CL� _ 1�{�.: _ --_ . l �'��� "�3r.� _r <br /> � _ ___ . _ - — - _- <br /> �-- <br /> I ('ces Ili,pnr.nlfi.��shydi��r� V�rd, . t%).��� ' <br /> F . —__ _. . __ _ _ _ _ _ '' — _.. <br /> i � -- -- nr.hvcry Icc;d nnl r.ovrered Uy labar i <br /> _.._. . -- -- -- <br /> — - -- <br /> Elir ible 7ofal = - ____- )�� - � �- - -� - -- (. . `_.. b-�?- -- , <br /> .�� <br /> Olhc.Costs ��OtiL;nnl assaa.ded tviUt HWf), .�nd ; <br /> not aliqiblc lur rr.b,dr: (dclail below) .. ___-- _ .-_-_— . --. -� � -- <br /> ---. _...- - - __"-- - �- - - . <br /> - -- - - -----� -- - - - - �4. �o�_�- Ux . �.11`✓�`^I4-V JQ71 �. <br /> -- - - . __ .. .. . __. _ . ._- . _ _ <br /> -- --- -. _. ._. � <br /> - - . —_ '"�k i ._._. ._- � <br /> . .-- .-_. _.. . __ - � --- <br /> . __ �- _._ . --- -- ��"�- - �e.:.�.bc,l(_. . <br /> �� - - ---- - . . . _ ._- - . _ .i i , <br /> _ _ � _ _—._ _ ,�/i7(�r _ <br /> Indiyiblc Total -� ----- - .. . , <br /> � Total __. ___ . _ . . . _i _ . . �.g."� (,'�/�,3'X � <br /> l2eviscd 9/03/2014 <br />