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i <br /> 47r BACKWATER PREVENTION PROGRAM <br /> INVOICE COST BREAKDOWN <br /> Please use this Invoice Cost Breakdown 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 w <br /> be submitted. This allows you to invoice your client according to your existing billing template while allowing <br /> city staff to identify how costs eligible for the Backwater Prevention Device Rebate were accrued. <br /> • <br /> Only labor and materials directly related to the installation and function of a backwater prevention <br /> device are eligible for City rebate and therefore should be included on the upper half of this form. <br /> Additional costs may be added to bottom of the form. l /� <br /> Business Name: �(,u4 2 / t�� License Number: f)I✓� l i r f 2c3 <br /> L <br /> Business Mailing Address: 4 (1 /,SST tk-- - &i1 T ///`"-'4- 917;7;3 <br /> City State <br /> Phone: 4'2 S:_- L S 2 `- ? 3 Email: p/ —1 /i t r -V7( 6.0-441-1-( 6.,___ <br /> ' <br /> Category Description Units Quantity Rate Total <br /> Administration Administration/management Hours <br /> Labor CCN Inspection Hours ( 5 )0 <br /> BWV Install Hours (' /z SZ) <br /> Pipe replacement Hours _ <br /> Surface restoration Hours l <br /> Site cleanup Hours l /5-0 <br /> Downspouts/drainage imp. Hours <br /> Materials Backwater valve Per Unit <br /> Grinder pump Per Unit ( 2f(-- <br /> Side sewer pipe(up to 8 feet) Feet <br /> Imported Backfill Yards <br /> Surface Restoration Materials Lump <br /> (top soil, grass seed, concrete, etc.) sum ( 5 <br /> Cover(irrigation box or load bearing Per Unit <br /> cover) <br /> Rentals Specify equipment Hour <br /> • <br /> Fees ' posal fees b ' em Yards <br /> i -- ( �,c.) <br /> Delivery fees if not covered by labor <br /> Eligible Total $ <br /> Other Costs Costs not associated with BWD, and S,17 '2_77..7i, <br /> not eligible for rebate (detail below) <br /> 3 C9 <br /> 2°1' <br /> _ ' <br /> Ineligible Total <br /> Total $ <br /> Revised 9/03/2014 <br />