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/. 1 <br /> , <br /> BACKWATER PREVENTION PROGRAM <br /> INVOICE COST BREAKDOWN <br /> Please use this Invoice Cost Breakdovon as � template for invoices submitted as part of the Backwater <br /> Prevenlion Device rebate program. Either thi; form or your own invoice form with the following line ilems can <br /> be submitted. This alloH s you to invoice your c.'ient according to your existing billing template while allowing <br /> city staH to identify how costs eligible fcr the Backwater Prevention Device Rebate were accrued. <br /> Onl�labor and maferials dlrectly relrrfed to the installation and funcfJon of a backwater prevention <br /> device are eligible for City rebate��nd thei efore should be included on the upper half of this form. <br /> .�dditiona!costs may b�added to bc!tom ol1'he lorm. <br /> Business Name: _��,(Q�z�f���[�L_. License Number: _������� _ <br /> Business Mailing Address:_�rp�I`�!/i�YLL/1'�'1 �� .�12T �� �C���_ <br /> Phone:�L�P �`E�2 � Email:_�� �Nit{�ll Z�C t �/7_ ' I���'1 <br /> Cate o Descri tion Units Quantit Rate Total <br /> Administralio� Administration/managemenl Hours <br /> Lahor CCTV Inspection Hows � <br /> BWV Install Hours 2S�j <br /> Pipe replacement Hours <br /> Surface reslorelion Hours � <br /> Site cleanup Hours <br /> Downspouts/drainage imp. Hours � Q <br /> Materials Backwaler valve Per Unit ��� <br /> Grinder pump Per Unit <br /> Side sewer pipe(up l0 8 feet) Feel <br /> Imported Backfill Yards � — _ <br /> Surface Restoration Malerials Lump <br /> lo soil, grass seed,concrel0. elc. sum <br /> Cover(irrigation box or load bearing Per Unit ( � S <br /> caver <br /> Rentals Specify equipment Hour <br /> Fees Disposal(ees by item Yards <br /> IYt,W .-------- -- ��� D <br /> Delivery fees if not covcred by labor ____ __ _ <br /> EligibleTotal - - ----�— - -5- z� <br /> Other Costs Costs not associated with BWD,and <br /> not elic�ible far rebate detail below <br /> - v <br /> IneligibleTotal ' S <br /> Total $ <br /> � <br /> , -�C,.� �y�,� • ��- <br /> Revised 9/03l2014 � <br /> ( <br />