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BACKWATER PREVENTION PROGRAM <br /> INVOICE COST BREAKDOWM <br /> Please use this Invoice Cost 8reakdown as a template for invoices submitted as part of Ihe'Backwater <br /> Prevenlion Device rebate program. Eilher this form or your own invoice form with lhe following line items can <br /> be submilled. This allows you to invoice your clienl according to your existing billing template while allowing <br /> city staH to identify how costs eligible for the Backwater Prevention Device Rebate were accrued. <br /> Only labo�and materials directiy related to the installation and/unctfon of a backwate�prevention <br /> device are eligible for City rebate and therefore should 6e included on the uppo►half of this /orm. <br /> Addilional cosfs may be added fo boftom of fhe lorm. <br /> Business Name: �- Gi�� inu �,L� License Number: �/Q-���i�niiP�n <br /> 8usiness Mailing Address: - � ��`_i�����J'�� �� -����'�� ��- 9��g <br /> Ciry State Zip <br /> Phone: �S ' �-I�`�—U/`Z � Emai�: /��9-PI��Z,�oi�'�°� /r� �4� `' �r�-V1zL,C�'� <br /> Category Descri tion Units �uanti Rate Total <br /> Administration Administrelion/managemenl liours <br /> Labor CCN Inspeclion Hours � (S� <br /> 6WV Inslall Hours Z. <br /> Pipe replacement Hours <br /> Sudace restoration Hours � 2 , <br /> Sile cleanup Hours � � S� <br /> Downspoulsldrainageimp. Hours <br /> Materials Backwaler vaive Per L'nit _ <br /> Grindcr pump Fer Unit ' r _ <br /> Side sewer pipe(up to 8 feetj Feet / y l - <br /> �� <br /> Imported Backfill Yards <br /> Surface Resloration Malerials Lump <br /> lo soil,_grass seed concrele,etc.) sum <br /> Cover(irti�alion box or load bearing Per Unit <br /> coverj_ <br /> Rentals Specify�iipmenl Hour <br /> "�' __ �_ -'JC� <br /> Fees Disposal fees by item Yards <br /> Detivery fees if not covered by loaor _ __ ___ <br /> -- --- - -- -- — —- -- <br /> Eli ibleToWl -- -` --- - i- --- — � _2�— <br /> Othcr Costs Cosls not assor.iat�d wilh BWO,and p �-7� � <br /> _ ___ nol cli ible for re�ate delail beinw _ ___ __� <br /> _�� 30 <br /> Ineligiblc Total S <br /> Total -- - S -- <br /> Revised 9/03/2014 <br />