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BACKWATER PREVENTION PROGRAM <br /> INVOICE COST BREAKDOWN �3Z� T'.�rr�c� <br /> Please use this Invoice Cost Breakdown as a tempiafe 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 s�!bmit!eu. This allows you to invoice your client according to your existing billing template while allowing <br /> ci[��staff to identify how costs eligible for the Backwater Prevention Device Rebate were accrued. <br /> Only labor and materials direct/y related to the installation and function of a backwater prevention <br /> device are eligible for City rebate and therefore should be included on the �pper haff of this form. <br /> Additiona!cosfs may be added to botfom of the(orm. <br /> eusiness Name: �i�(10 �c��� License Number: �pOLf�/ 9'IS�1�' <br /> Business Mailing Address: S�^� `71�� Av� � F�uY�' �n/ti g8��(� <br /> City Slate Zip <br /> Phone: Email: <br /> Cate o Descri tion Units Quanti Rata Total <br /> Administration Adminisiration I managemenl Hours <br /> Labor CCN Inspeciion Hours (7U <br /> BNN Install Hours �� <br /> Pipe replacement Hours <br /> Surface restoration Hours <br /> Site cleanup Hours (� <br /> Downspouts I drainage imp. Hours <br /> Materials Backwatervalve PerUnit .�— <br /> Grinde�pump Per Unil <br /> Side sewer pipe(up to 6 feel) Feet _ <br /> Imported Backfill Yards ' <br /> Surtace Restoration Materials Lump <br /> to soil, rass seed,concrele,etc. sum <br /> Cover(irrigalion hox or load bearing Per Unil <br /> cover <br /> Rentals Specify equipment Hour <br /> Fees Disposal fees by i�em Yards <br /> Delivary fees if not cavered by labor <br /> Eli ible Total $ <br /> Other Costs Costs not associated with BWD, and <br /> not eli ible for rebale delail 6elow <br /> Ineligible Total $ <br /> Total r� <br /> �?�J � <br /> Revis�d 9/03/2014 <br />