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BACKWATER PREVENTION PROGRAM <br /> E" INVOICE COST BREAKDOWN <br /> Flease use this Invoice Cost Breakdown as a template for in��oices submitted as part of the Back�valer <br /> Prevention Device rebale program. Either this torm or your own invoice (orm wilh the follo�ving line items can <br /> be submitted. This allows you to invoice your client according to your existing billing template while allowing <br /> city sta(f to identify how costs eligible for the Bar,kwater Prevention Device Rebate were accrued. <br /> Oniy labor and materials directly related to the irstallafion and lunction oi a backwater prevention <br /> device are eligible for City rebafe and there/ore shauld be included on the upper ha!/of fhis lorm. <br /> Addifional costs may be added to bott�m o/fhe Inrm. <br /> E3usiness Name: ��}- pl Uh� b�✓� �L� License Number. !�?�I�I���'07/ �� <br /> J <br /> BusinessMailingAddress: 1��0�� V���'tl.✓�Q-INL�L I�� EV�1�� �n1't� 9 �SL� <br /> City State Zip <br /> Phone:� 2) - �Qi�1-O(2�j _ EmaiL• GtQ�J��n� l�lV2A1LL- �-�f7 �' ���fht • G�^'� <br /> Cale ar Description Units Ouantit Rate Tota� <br /> � Administralion �dministralion I managemenl Hours <br /> I` Labor CCN Inspection Hours �00 <br /> I BWV Install Hours i �5 U <br /> i- - <br /> Pipe replacement Hours _�__ � "Z� <br /> iSurface restoraGon Hours � L/ Q <br /> Site cleanup Hours <br /> � Do::nspouls/drainage imp. Hours L <br /> Materials Baclnvater valve Per Unil S� <br /> Grinder pump Per Uml <br /> Side sewer pipe (up tn 8(eel) Feet <br /> ImpoAecf Dackf�ll Yards <br /> Surlace Resloraiion Materials Lump / / D� <br /> _ lo�soit,grass seed, concrele, etc. sum <br /> , Cover(irrigation bnx or load beariny Per Unit / � U U <br /> cover <br /> fReNals Specity equipment , _ Hour <br /> �- ----- <br /> Fees DIS�OSflI�P.CS Ily dem Yards � �r <br /> � � <br /> -- -- - - - -- --�: -- � <br /> — ------ <br /> Delivery fees il not r.overed by labor <br /> — -- - — _-�- - -- - <br /> � EII ible Total � � � ��� <br /> Othe�Costs Costs not associated wilh BWD,and <br /> not eli�c�or reba�e(detaii belo�v) _ _.___ ___ <br /> ,I -- — ---- — _ <br /> � --- - - — -- UU <br /> i -- --- — -- - � <br /> I Ineligi6le Total � <br /> Total - --- - --- - - � - -- - -- -- - S <br /> Revised 9/03/?014 <br /> , <br />