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BACKWATER PREVEIVTION PROGRAM <br />� INVOICE COST BREAKDOWN <br />Please use this Invoice Cost Breakdown as a template for invoices submitted as parl o( the Backwater <br />� Pieverdion De:vice rebate program. Either this form or.your own invoice form with t`�e following line items can <br />be sunmitted. 'fhis allows you to invoice your ciient according to your exisiing billing lempiate while allowing <br />ciry staff to idenlify ho�v costs eligibie for the Backwater Prevention Device Rebate were accrued. <br />Only labor ar.�� malerials directly related to the installation and f�nction of a backwater prevention <br />device are eligible for Ciry rebate and the�efore should be incl�ded on the upperhalf of thfs form. <br />Addltional costs may he added lo bottom ol the lomt. � <br />S�;�Rr'r-, l, <br />Business NBme:�j�1�'(��czl']_i_SC'�L��.SiC��'— License Number. _�5�� �i : <br />Business Mailing Addiess: <br />Zip <br />Phone:,���C%�i�Si,-� Email _(�,:�����Cc�c��� -[3t�d���i�3'�=-�� <br />Rcvised 9/03/2014 <br />