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� <br /> ; <br /> i <br /> BAt�KWATER PREVENTIO�I PROGRAM � <br /> INVOICE COST BREAKC�OWN � <br /> � <br /> Please use this Invoice Cost Breakdown as a template for invoices submitted as part of the Backwater i <br /> PrevenHon Device rebete program. Either this fortn or your own invoice form wfth the following line items pn i <br /> be submitled. This aliows you to invoice your client according to your existing billing tempiate while allowing <br /> city staff to identify how costs eligihle for the Beckwater Prevention Device Rebate were accnied. � <br /> Onty labor and materials di��ctfy rela�ed to 'he installation and function of a bar.kwater preventlon ,' <br /> devfce are e/igib/e for City rebate and ffie�e/orie should br included on the upper half o/this /orm. ! <br /> Additional costs m.�be added to boftom ol fhe lorm. � <br /> Business Name:�Q��- Q� �U1��,f�f Vl •_`t�_License Number.�,�/ ���Ol/` I-� I <br /> Business Mailing Address: � b �� V�S / �'� �n�- IJ� � '�T���T � <br /> , Ic� �/ Ci State Zi ; <br /> Phone: �ZS ` `-� U � C�( Z j Email: ��l f�/ vl��/✓�C 2�1� �t'`l�'7 /��L�� ! <br /> � <br /> Ca o Descri tion Units Uua ' Rate Totel { <br /> Administration Administretion/management Hours V i <br /> Labor CCNins ection Hours CS t� <br /> BWV Install Hours � � j <br /> Pipe replacement Hours � <br /> Surface testoradon Nours -� � � <br /> Site deanup Hours —17 ! <br /> Downs oufs/drainage im . Hours % <br /> Meterists BackwatervaNe Pe�Unit �3 ; <br /> Grinder ump Per Unit � <br /> Side sewer i � <br /> p pe(up ta 8 feet) Feet ' <br /> Imported Backfiil Yards � �L L'� + <br /> Surfaoe ResWraHon Materials Lump i � <br /> lo soil, rass seed concrele,etc. sum ; <br /> Cover(irtigadon box or load beanng Per Unit '. <br /> cover � 2 5� ; <br /> Rentals Specify equipmenl Hour ' <br /> i <br /> F s Disposal fees by item Yards • � <br /> — — y'-U ' <br /> Delivery fees if not covered by labor /� j <br /> i � <br /> i <br /> Efl ible Totnl �� $ ' <br /> Costs not associated witA BWD,and , �1� _ ! <br /> Other Costs not eli ible for rebate detall below ' JZ�' <br /> i <br /> -- ! <br /> t <br /> _ _ �� .-. � <br /> Indi ible ToTal ` g �_ � <br /> Total $ <br /> i <br /> i <br /> Revised 9/03/2014 ' <br />