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BACKWATEF� PREVENTION PROGRAM <br />� INVOICE �OST BREAKDOWN <br />Please use ihis Irivoice CoSI Breakdotvn as a template for invoices submitted as part of the Backwater <br />Prevention Device rebate program. Either this form or your own invoice form with the following line items can <br />be subnitted. This allows you to invoice your clienl according to your exisling billing template v�hile alluwing <br />city st�if to identify how costs eligible for the Bsck�vater Prevention Device Rebate were accrued. <br />Only labor and ma4erlals directly related to tfte installation and function of a baclnvafer prevention <br />devlce are ellgible for Ciry rebate and therefore should be included on the upper half of fhrs form. <br />Additional costs ��}� b��adde� to 6ottorn of the (orm. <br />J� 'i� �fU�L�, �165�/Ss8 1'�_ <br />Business Name: �t,�� SE"'X� License Number. <br />a(of�.Si SW Gct'nor��5 u)�4 ago�� <br />eusiness Mailing Address: 3 � ' - • I�,' <br />L Abxl�T�� �, an4.s�P��t��''' Z�P - <br />Phone: <br />�� y%-✓`� - l/q3 Email� a�` co,r� <br />Revised 9/03/2014 <br />