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� <br /> � <br /> BAGKINA�TER PREVENTION PROGRAM ; <br /> INVCIICE C�ST BREAKDOWN ; <br /> Please use this Invoice Cost Breakdown as a t.�mplate for invoices submiHed as part of the Backwater � <br /> Prevention Device rebate program. Eilher this fo;m or your own invoice form with lhe following line items can <br /> be submitted. This allows you to invoice your client according to your existing billing lemplate while allowing � <br /> city siafi to identify how costs eligible for the Backwat=r Prevention Device Rebate were accrued. <br /> Only labor and materials directly related fo the i�istallation and function ol a backwafer prevention <br /> device are eligible for City rebate and the�efore should be included on the upper half ot this fo�m. i <br /> Additional costs may be added to bottom o!the Iorrr. <br /> Business Name: ��.(,�� �_icense Number: <br /> f� Pl�l�'tf/�Q I <br /> L I <br /> Business Mailing Address� �(�� �� /1''Ti��Va'���7� ��T W`" ��d� I <br /> C,I� e St818 � <br /> �l 5` � c�(2?j Email:! A� /� l !� t+—� LG� 2�_/�LS�*''sh����' <br /> T <br /> Phone: _ <br /> Catc or Description —r�nits Quanlil/ Rate Total <br /> Admi�istration Admini,>t�ation/management Hours <br /> Labor CCNlnspeclion Hours � O'T} <br /> BWV Install Hou s � <br /> Pipe replacement Houis <br /> Suriace resloralion Hcurs 2 <br /> Site cleanup Hours U <br /> Downspouts I drainage imp. Hours <br /> M�terials Backwater valve Per Unit <br /> Grinder ump Per Unit 2I� <br /> Side sewer pipe(up to 8 feet) Feet _ <br /> lmported Backfill Yards <br /> Surface Restoration Mat�nals Lump �/ <br /> to soil, grass seed concrete etc.) sum � <br /> Cover firrigation box or load bearing Per Unit <br /> cover — <br /> Rentals Speciry equipmenl Hour <br /> Fees posal fees�tem Yards <br /> 1 -- v -- <br /> Delivery fees if not covered by labor —__ <br /> E�Io Total ----— --- — $ — <br /> Cos1s not associated wilh BWD, and 2Z""� � <br /> Othcr Costs not eliqibl�for rebate (delail betow _ . _ `�� <br /> � <br /> -- --- — —����- T <br /> — -- — - � C7 <br /> Incligible Total <br /> Tote7 _ _ _ — --- $ <br /> Revised 9/03/2014 <br />