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BACKW'ATER PREVENTION PROGRAM <br /> � INVOICE COST BREAKDOWN <br /> Please use this Invoice Cost Breakdown as a templale (or invoices submilted as part of the Backwater <br /> Prevention Device rebate program. Either this form or your own invoice form tivith the following line items can <br /> be submitted. This allows you to invoice your client according to your existing billing lemplate while aliowiny <br /> city staN to identify how costs elie�ible for the Backwater Prevention Device Rebate were accrued. <br /> Only labor and materials directly relafed to tire lnstallation and function of a backwater prevention <br /> device are eligi6le torCity•rebate and therefore shoufd be included on ihe upper hal.'of this form. <br /> Additional costs may be added to bottom o(the (orm. <br /> S�c�'�,t,�-�% /1 <br /> Business Name:�y7�j�� �� ' 'Gq�-: t['Je_License Number: _QS��'7�� <br /> �usiness Mailing Address: v��i.��c: LCt rlcl�l C./V�--___/�(1/��� f.l�r9 �c��.� <br /> Cily State Zip <br /> Phone: ���'�lC��"�Y2� Email:(�_Q�j41AL�CL(C���hE;<ifi�.��-�l_}___'.��'J,F�r F",(: (k� <br /> Catc o Descri tion Units �uantit Rale 7otal <br /> Adminis[ration Administration/managemenl Hours <br /> Labor CCTV Inspection Hours _ <br /> BNN Install Hours <br /> Pipe replacement Hours <br /> Surface restoration Hours �� <br /> Silo cicanup Hours <br /> Downspouts I drainage imp. Hours _ <br /> Materials Dackwater valve Per Unit �- 1 � <br /> Grinder pump Per Unit <br /> Side se�ver i e(up to 8 feet) Feet .�< << <br /> Imported Back(dl Yards _ <br /> Suriace Resloration Materinls ��mP 3� <br /> to soil,yrass seed,eoncrete,elc. sum <br /> Cover(irrigation box or load bearing Per Unil a ,a <br /> cover) _ <br /> Rentals Specify equipmenl � Hour _ <br /> -r� —1- — —� J�� —"3a�� <br /> Fees Dis osal tees by item Yards_ - ��LpL_/ � <br /> � <br /> Dr.livery fees if nal covcred by labor ________ _ <br /> Eli Ible To[al � � <br /> Olhcr Costs Costs nol associated wilh BWD,and <br /> not e,�gible tor rebate(detail below <br /> Ut. b cc•+vutar ' w V1S0.�S <br /> _ �_� <br /> �wu+r <br /> c rr <br /> Incligible Total $ <br /> rocai � ' 3 . <br /> Revised 9/03/2014 <br />