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BACKWA�ER PREVENTION PROGRAM . <br /> � IRVOICE COST BREAKDOWN <br /> Please use this Invoice Cost Breakdown as a template for invoices submitted as pari of the Back�vater <br /> P�evention Device rebate program. Either this form or your own invcice form with lhe following line items can <br /> be submitted. This allows you io invoice your client according to your exisling uilling }emplate while allowing <br /> city staN to identify how costs eligible for the Backwater Prevention Device Rebate evere a��rued. <br /> Only fabor and materials direcNy related to the Installation and function of a backwater pievention <br /> device are eligible for City rebate and therefore should be included on the upper half ot tliis fo►m. <br /> Additiona�costs may be added fo bottom o(the foRn. <br /> 5����, t-�-�' S•,�� <br /> Business Name:��j.(tzl� �r,��-- +,�-S;rle License Number. (� ,'� <br /> Business Mailing Address: oZ�:°-� LG"c c �l i-!1�--- ��(!1"�t�tt_-u--�Q U�`��'3 <br /> City State Zip <br /> Phone:���fC� ';�'�15�. Email_C,. {� ��c30.�,� �� L1���Nu- •�'r c•cs�n <br /> Cate�ory Descri�n_ Units Lluanti Ratc Total <br /> Administretion Administ�ation/management �lours <br /> Labor CCN Inspection Hours _ �S� <br /> gWV Inslall Hours <br /> Pipe replacement Hours _ <br /> Surface restoral on Hnurs _ � <br /> Site cleanup Hours __ _ <br /> Uownspouls I draina�e imp. Hours <br /> Matcria�s Oackwater valvc Pcr Uni� 1 �� �_l(���'",1�]� 0�.� <br /> Grinde�pump Per Unit <br /> Side sewer pipe(up l0 8 feet) Feel I� (� � ,�__ec'�� <br /> Imporled Eiackfill Yards ___ __ <br /> Surf�ce Restor�tion Mntcrinls Lump � �� <br /> �lOp 5011,grass seed, c:oncrete,etc.)__ sum <br /> Cover(irrigation box or load bearing Per Unit / � 1 � <br /> caver --- - --- --1— � <br /> Rentals Soer.ify equipmenl _ Hour __ <br /> _____`C.4L.�._CLC-GI��----- — - --1-�_�J..� -�r� - <br /> -------- ---- <br /> _e,a�-�- <br /> Fees Di�nos�l fces by item Vards <br /> -- - Delivery iecs If not coverod hy Itibor --- - -- ---- _-- -- <br /> Eli ible Total - -C - -- - - - - - - ^2- - -� a - - - <br /> Other Costs Cosls nol assooialerl e+ith 13WD. ��nd <br /> not eliqible for rebale (detail below) __ , _-____ <br /> --- �— - ------ -�- -- -- _ 0�1, tt �.�w} cn^y�1�—M^w1I_" 1tf <br /> _Q <br /> --- -- �-- - - �---- ---- <br /> - <br /> -�---- � - -- <br /> -- -- ----- ---- - -���- - --�- <br /> --- ------- --- ---- - - . ,y/ <br /> "__—i-l�i . _ . M�CaU _ <br /> . _.___--_ — - <br /> _____—.__._..-- _ ____ '__� 122�IT__ <br /> �-- - - — -'--�--- ---- ------- — � �- <br /> Incligiblc Tatal <br /> Total __ _ _ _ -— -- -- — � . r,'� -< <br /> Revisod 9/03/2014 <br />