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. i <br /> � <br /> BACKWATER PREVENTION PROGRAM � <br /> INVOICE COST BREAKDOWN � <br /> i <br /> Please use this Invoice Cosi Breakdown as a temolate for invoices submitted as part oi the Backwaler 1 <br /> � Prevention Device rebate prograrn. Either this form or your own invoice form with the following line items can � <br /> be submitted. This allows you to invoice your client according to your existing billing iemplate while allowing � <br /> city staff io identify how costs eligible for the Backwaler Prevention Device Rebate were accrued. � <br /> Onlylabor and materials directfy related to fhe installaflon and function of a backwater prevenfion ; <br /> device are eligible for City rebate and the�elore should 6e included on the upper half af this form. � <br /> Additional cos(s may 6o added to bottom of the �oim. � <br /> 51�i.�t'r L.LG /1 I <br /> Busi�ess Name: ic.. ���� P_ License Number: =�.,�T3�'7:� � <br /> �2 i <br /> Business Mailing Address: o��x.�n C.u„�cJ�t C.1��• (�(f'� . � _ �.rin.�L�=3 � <br /> City State Zip ����yy I <br /> Phone:,.���L��Si� Email:�' � '� �Ci�ss��ll�ic���n.I ti riP,SYf.L�'�•_ ��li'/J <br /> i <br /> Catc o Descri tion Units Quanti _Rate Total ' <br /> — — I <br /> Administration Administration/manayemwt Hours ____ _ � <br /> Labor CC7V Inspec�ion Hours _ � <br /> _�___ _. — �. i <br /> BWV Install Hours _ __ I <br /> Pipe replacement hlours _ ; <br /> Surfuce restoralion Hours � ! <br /> Si�e cleanup I-lours � � � <br /> Oownspouls/drainage imp. HoUrs _ ! <br /> Materials Oackwaler valve Pr,r Unit —3— <br /> -- �--�- L(x�i'f-5� ----a�-- i <br /> �Grinder pump Per Unit ; <br /> SiAe sewer pipe(up to 8 fee� �eet �` �' � _____ <br /> i <br /> Imported Backfill Yards ___ , __ i <br /> � Sutiacc Rcstoralion Materials Lump j <br /> —LFlo sr,il rass seed concrete elc. sum _�_ 3� 3 v i <br /> �9----'— ' --- <br /> Cover(irrigation box or load hearing Per Unil ' <br /> �_.�- ; <br /> Rentals Sperify equipment - -Elour --—�— ( �------ - _— i <br /> ---- —��-� ��— ——�-- 3vn 3��a_--: � <br /> — --------- --- - - ---'7 ; <br /> Fees Di�pns�l(cr.s by 8em ----- Yards __ ./� �•� / . <br /> __.—_ -- �---'--�------ � <br /> ---- � - ----' i <br /> - � prlivcry fecs if not r.ovrrr.d by labor _ _ _ _ ____ ___. ____ <br /> ----- -----------— — - - ; <br /> EII ihle Total — -- — - - —- --- — O� • '� ' �� ' - <br /> i <br /> Other Costs �osts not assaciated with BWD, w�d ' <br /> nol eli ig'bIC IOr rebate(detail below)_ _ _ __ � <br /> ---- -- --- - -- - —z��- ; <br /> � <br /> ------ ——- ---- ���Z—�—r� � i <br /> — — —— V��N u� �0 ' S � <br /> -- - - —� �,''_r_vr� I , <br /> - - -----r"-- -�-�"��� I <br /> - --- � . <br /> Ineligiblo Total ' <br /> Total - -- � ��3 - — � <br /> i <br /> Revised 9/03/20i4 <br />