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BACKWAT�R PREVENTION PROGRAM I' <br /> INVOICE �OST BREAKDfJWN <br /> Please use this Involce Cost Breakdown as a lemplate tor inwices submitted as paA ot the Backwater <br /> Prevantion Device rebate prc,gram. Eithor Ihis fortn or y;wr:�wn invace form with the(olbwing line items can <br /> 6e submitted.This albws you to inwice ynur client accoroing ro your existing billiny template while albwing <br /> dty sta(�to idantity how costs oligible for fhe 8eckweler Prev�ntion Devlce Rebate were accrued. <br /> Onty faDor and maferinls directly relsfed to fhe instellallort�nd function ot a backwriter preventlon i <br /> dev7ce are dlgiWe for Cit�nebatr�and themfo►e should be included on fhe upper haH of thfs fortn. <br /> Addi6onal costs may be added to bottom ol the lo+m• <br /> E3usiness Name: �� �L1'�7 bll�.,� �C License Number. �fr�l.�sl����-- : <br /> 8 i� 1`�II1�ttu.ra,nn� ��LT 9c�'��8 <br /> Business Maili�g Address� � <br /> Gj�y gtale _ Zip . <br /> Phnne� L�2� ���DlZ3 Email: �PjV�� �����- <br /> Catego�_ DescriVlion _-- Units auantity Rabe Total <br /> Adminishation Administratirn I management Hours . <br /> labor CCN Inspeciion Hours _/ ',� '�. <br /> � BWV Install ._ Haurs / ��_�� - ' <br /> Pipe replacemenl Hours _ <br /> Sudace restomGon Hours � - <br /> - Sile dcanup Hours f <br /> Dow�pou�/drainaqc imP- Hours ; <br /> Materials Backxatervatve -- PerUnit _�___ _2.�� �. <br /> � Grinder pump Per Unit _, <br /> ---- Side scwer pipc(up W 8 feet) Feet , <br /> , <br /> -- Impodcd Backfill Yortls--- --- ' <br /> �� SuAace Restnration D,Inlcriuls Wmp / - 1J� . <br /> �f <br /> ;o sol, ress seed,concrete.elc. sum <br /> - ' Cover(irtigalion trox or load beanng Per Unil <br /> cover) --_ � <br /> Rontals S edf w menl Hnur _ <br /> ------ �- Y�-------- - <br /> Fces -_- -Disposal tecs by item _ � _ Yart3s_ _ -- _._ - <br /> -- �- - � — — � �U - - - - <br /> ' --- - -- <br /> - -- - -- ---- <br /> Delive yr lees if nW covcrnd try la6or .. � <br /> :- - . ---- - --. - '. <br /> - - -- - �7_� <br /> _.._ — --- . . — . . __ _ _�-G���S � <br /> Eli i61e Tolai �-- --. . <br /> C�h not associeied vnlh BWU,nnd � <br /> Olher CoS�S not eli ble for rr.bale dclnil below - � <br /> �. _�_-- —'— �--�---- '-- -�- - - <br /> — - -- -- — �------ -- <br /> � <br /> r - -- -- -- --- ' ��-�:.-'f <br /> - -- <br /> --- --- <br /> --- -- <br /> _ -- --- --- - -- - - ---- - - )Ln <br /> -- - --------- $ -�- . <br /> Incli ible Totel � <br /> $ <br /> Totai ----- ------ --- - - -- - ----- -- <br /> Revised 9N3PZ014 <br />