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BACKI!VATER PREVENTION PROGRAM <br /> I�JVOICE COST BREAKDOWN <br /> Please use this Invoi�e Cost Breakrown as a lemplate for invoices submitted as pa�t of the Backwater <br /> Prevention Device rebate program. Either ihis toTn or your own invoi�e form wiln the following line items can <br /> be submitted. This allo�vs you to invoice your clienl according to your existing billing Iempiale while allo�aing <br /> cily staH to identify how costs elir�ible for the Backv�dter Prevention Device Rebate were accrued. <br /> Only labor and materials direcfly refafed to the fnstallation and function of a backwater prevention � <br /> device are eligible for Cfty rebate and fherefore should be irtcluded on the upper half of this form. <br /> Addifional costs may 6e added to boliom of the /orm. <br /> 5��,��-, t,t,c% /y <br /> Business Name:�q Cr'F� �a- ��' License Number. _�rJ�1�_.— <br /> Business Mailing Address: o��C�o (�CX_[��l�l f��E-• T!�"-I''�'��—LI�A g`�`��� I <br /> City Stale Zip <br /> Phone:�lF,'.�fG '�.���. Email:(��l��inm�rrcan��lHi�[3�1c�4;t�i�, .N�. . C• � <br /> Catcqory Doseri tion Units I Ouanti Rate Total <br /> AdministreHon Administration/management Hours I <br /> Labor CCTV Inspection Hours _� � _ _ � <br /> gNN install Hours � <br /> �— pipe replacement Hours _ � i <br /> � Surface restoralion Hours � <br /> j Site cleanup Hours I <br /> Doa�nspouls/drainago imp. Hours <br /> Matorials Oackwaler valve Per Unit �C � � _�_��� � __�S�,_ <br /> Grindcr pump Per Unit I <br /> Side sewer pipe(up l0 8 feet) Feet '� �� y� <br /> Imported Dackfill _ Yards _ <br /> Surface Restoralion Metcrials Lump / v <br /> �soil, rag ss seed concrete, etc. sum i <br /> Cover(irrigation box or load beanng Per UNl r� !� <br /> cover �__ _ <br /> Rentals Specify equipment Hour <br /> � I "�?L �' t� — <br /> Fees Disposal fr.r.s by ilr_m Yafds , ��'� . <br /> Oeiive fecs If not covereA by labor __ _ ___ _ <br /> Eli ible Total . C..'�1cd � $ ��'` <br /> othcr Costs Cosis nol associated with BWD,and <br /> not eli9ible for rebate �detail below __ _ ___ <br /> -- l� (-o G.ti!-rs`c h..v �- u17 7} <br /> --- — f '� I <br /> --. _.— _ -- � � <br /> IneliglbleToUl 5 �O '���� <br /> Total — ---- ---- S—��_ <br /> Revised 9iO3/2014 <br /> I <br />