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BACKWATER PREVENTION PROGRAM <br /> I[VVOICE COST BREAKDOWN <br /> Please use this Invoice Cost Breakdown as a tomplate for invoices su6mitted as part of ihe Back�vater <br /> , Prevention Device rebate program. Either this iurm or your own invoice form with the follo�^�ing line items can <br /> be submitted. This allows you to invoice your client according lo your existing billing template while allowing <br /> cily staff to identify how costs eligible for the Bar,kwater Prevention Device Rebate were accrued. <br /> Only labor and materials directly related to the installairon and funcfion of a backwater prevenfion <br /> devlce are eligible for Ciry rebate and there(ore should be included on the upper flalf of this form• <br /> Additional cc ts may be added lo boHom of the (orm. � <br /> 5����,�, <br /> Business Na�ne:Q�'I��j�tz12�r'.��—LW!��e License t�umber._p�,Z�� <br /> Business Mailing Address: o��O LU_� c l-1 �� ��U'L�it�4t[t�����c�:3 <br /> City State Zip <br /> Phone:.�.,(o=��c��Y��� Email:� ['l1lYCl.lrc,'2��31�d-.�t'�i-2'L•�L�l <br /> Cate o Uescriplion Units Quantity Rate Total <br /> Administration Adminisiration/manapement Hours _ <br /> Labor CCTV Inspeclion � Hours _ "�� <br /> BWV Inslall Hours __ <br /> Pipe replacement Hours _ <br /> Swface resroration Hours '�7- <br /> — Hours - �- — <br /> Sile cleanup -- <br /> Downspouts/druinage imp. Hours <br /> Materials 5ackwaler valve Per Unil _L �S��y' �pU'��� _ �� <br /> Grinder pump Per Unft � _ <br /> ---- Side sewer pipe(up to 8 feel) ---- - Fecl J L��-,� _��_�7 <br /> Imported Backfill Yards _ ___ <br /> Surfacc Restoration M�leri�ls Lurnp <br /> t�o�soil,grass seecl, concrele,etc.)_ sum _ �_ __�C�_ <br /> ---�- -- Cover(irriga�ion box or load bearing Per Unil <br /> c�ver)-- -- - -- --- —--�— �- _ <br /> Renta�s f Spr.cify equipment Hour_ _ <br /> -- -��.�� <br /> ---- <br /> - --- -- -�✓l.1GlC—�:`-"�--- -- - ---�—--��---��JF�--- <br /> - --— <br /> — --- — ------ <br /> - -- ----- V�rdr. <br /> Fees Dicposal fer_s V�y ilem -. __ -- - ----- —-_-. -.- -- - . _ . .--.- . <br /> nr.livery ler.s if nol covrred by labnr _ _ _ _ _ _.__ _ _ _ . _ _ <br /> ._ —--- -- --- - ---- -- _.. - <br /> Eli ibleTotal - --- -- -- --� �- - -- — $ <br /> Other Cos�s ��Sls nul:�s;;uc!aled tivdh f3WD, und <br /> nnt eligibie(or rrbate(detail below) _ _ _ __ __ ___ _ __ _ <br /> - - - <br /> --- - — - <br /> -- - -- -- --- — . — -- <br /> G Fv �e�iy_ cc-� .a«•Iw__F�,.,��q•___v _'47J--- - <br /> -- ----- ----- - -- � <br /> ------- - - --' --- - --- ��l.m,�. �. ---- <br /> -- - - <br /> -- - -y-- -- ---- -- <br /> ---- - -- ---- {�u_r4•�_�`-- �.,u— <br /> IneligibleTotal "--- -- -- - - -- Z� $ - -- <br /> Total - -- --- ---- �r-'-2- �i �- < <br /> Reviscd�J/03/2014 <br />