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t <br /> ����■t A��i ■ ����{�� R ��17 r ������Yf <br /> � � 'V� ��� ������o■• �■ <br /> Please use this Invoice Cost Breakdown as a template fior invoices submitted as pa�#of the Backwater <br /> Prevention Device rebate program. Either thes form or your own inv�ice form avith the following line items can <br /> be submitted. This allows you to invoice your client according to y�ur existing billing template while altowing <br /> city staff to identify haw costs eligible for the B�ckwater Prev�ntion Device Reba#e were accrued. <br /> Only labor�etd trraterlals directly r�taf�d fo fh�ira�fall�tion�rfd funcfion of a�ackw�ter prevention � <br /> device are eligible for City rebate ant�therefCare shouBd�inClud�d on the sep�ser hal�e�f this form. ; <br /> Additiona!casts may be added to bvttom of the form. � <br /> Business l�ame: ��:''��' �� �' � �'�='� � ` License Number: `�����c� . .������ ` <br /> �� � <br /> Business M�iling A�ddress: `�� �.� (� �� ��..� �'"�',�,.i�,�.�, ,�"�€���_ ��-�-��. �.y`�._ `�;�.-��-�� <br /> a City State „ Zip <br /> Phone: ���...�`;;� ,�-.�'��-��_�f'�'��'�. Err�aiL ���t��� �_ � �• <br /> Cat� o D�scri tion Units �taan�i Rate T�t�i <br /> Adrnini�tratgon Administration/management Naurs <br /> l.atsor GCTV tnspe�t�on Hours � .`' �� <br /> BWV Iflstall F#ours �.. � <br /> Pipe replacem�nt H�urs �� �� �� � <br /> Surfac�restoration Hours �"""� 5 <br /> Site cleanup Nours <br /> Downspouts t drainage imp_ Hours <br /> Materials 6�cicwater valve Per Unit � <br /> Grinder pump Per Unit <br /> ���.��� Side sewer pipe(up to 8 feet) Feet � �' � <br /> '� �'° TM tmported Backfill Yards �a <br /> 5urface RestQration Materials Lump � ,� ���� <br /> �' �r�'��� to soil, rass seed,cancrete, etc. sum <br /> Cover(irrigation box or load b�aring Pe�U�it <br /> , �,•--�- � '� <br /> ,;�--�}_;�� (.t"�`{��� cover <br /> Rentals Specify equi ment Hour <br /> �..��"�-�-.�,``�_ `� � <br /> Fees Disposal fees by item Yards e <br /> Delivery fees if not cavered by labor <br /> �li ibie Total � � <br /> �� <br /> Cos#s not associated with BWD, and -� �~-� � <br /> Other Costs �at�li ible for reba#� detail below `°�' --� <br /> 3 <br /> � <br /> � <br /> _�, <br /> Ineligi�le Tota{ � " $ � � � � � <br /> Tatal � � <br /> ,�, C,� <br /> � <br /> R�vised 9/03/20i4 ' <br /> 1 <br />