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BACKWATER PREVEYVTION PROGRAM <br />� INVOICE COST BREAKDOWN <br />Please use this Invoice Cost Ereakdown as a template tor invoices submitted as pa�t of the Backwater <br />f'revention Device rehate prog�am. Either this form or your own invoice form with the follotving line items can <br />be submitted. This allo.as you tu nvoice your clienl according to your existing billing template while allowing <br />city staff io identify hov� costs E�ligible for the 8ackwater Prevention Device Rebate evere accrued. <br />Onlylabor and materials dirErctly related to the installation and funcfion of a baclnvater prevention <br />device are eligible for City rebate anc' therefore should be includetl on the upper half of this form. <br />Additional costs may be added to bottom of the form. � L� <br />� ��,,cJ�:�� i , • <br />Business Name:.� �1'1N(`jC�����-�'-��=��rr License Number: __(���' h�� _ <br />Business Mailing Address: cf(��-t� �.0 � u✓� �� ��-• �—v •�-� +-�` �' � <br />City State Zip <br />Phone:�Y •-�'���--�`5:.�, Email:�. °� 1h1�riC�;��M^�r3n�f �'rir4p-�2',(',C'cS� <br />Revised 9/03/2014 <br />