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BACKWATER PREVENTION PROGRAM <br /> -77 INVOICE T BREAKDOWN <br /> Please use this Invoice Cost Breakdown as a template for invoices submitted as part of the Backwater I <br /> Prevention Device rebate program. 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 template while allowing <br /> city staff to identify how costs eligible for the Backwater Prevention Device Rebate were accrued. <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. <br /> Business Name: 1 l'�of` zb s _ =`'mit License Number: (72 t y <br /> Business Mailing Address: S -�y Lat"`kpi I,0i(-- 6 'l� `' 0; R,�t),� <br /> City State Zip <br /> Phone:.' <br /> X:,1 x'1��0 <br /> Category Description Units Quantity Rate Total <br /> .Administration Administration/management Hours <br /> Labor CCTV Inspection Hours <br /> BVW Install Hours <br /> Pipe replacement Hours <br /> Surface restoration Hours <br /> Site cleanup Hours <br /> Downspouts/drainage imp. Hours <br /> Materials Backwater valve Per Unit <br /> Grinder pump Per Unit <br /> Side sewer pipe(up to 8 feet) Feet 11ttQ04- , 57 <br /> Imported Backfill Yards <br /> Surface Restoration Materials Lump <br /> (top sail,grass seed, concrete, etc. sum <br /> Cover(irrigation box or load bearing Per Unit <br /> cover) _ <br /> Rentals Specify equipment Hour <br /> Fees Disposal fees by item Yards <br /> Delivery fees if not covered by labor <br /> Eli ible Total I $ <br /> Other Costs Costs not associated with BWD,and <br /> not eligible for rebate detail below) <br /> Ineligible Total ,, <br /> Total <br /> Revised 9/0312014 g <br />