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BACKWHT�R PREVENT� AK�OWNRAM <br />INVQICE COST BRE <br />late for invoioes submitted as part of ihe Backwater <br />Piease use this Invoice Cost Breakdown as a temp our exisling billing template while allowing <br />Prevention Device rebate program. Either lhis form or your own invoice f�rm wilh the tollowing line items ca <br />be submitted. This allows you to invoice your client according lo Y <br />city staif to identiiy how costs eligible for ihe Backwateialafbntand functioneof a backwater prevention <br />Only labor and materials directly related to the �ns <br />er half of this form. <br />device are e►igib�e f tio 'dded�otboft mtof tho�foi,nh�uld be inc�ed on the upP <br />11ddit+onal costs maY SL�c�F'�r �' <br />: � ---- -- <br />���� . • �;� License Number. �� <br />=P� `=��= <br />Business Name: . n .� � i /�% <br />gusiness Mailing AddBss: <br />State Z�P <br />Revised 9/03/201� <br />