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BA�KW,�4�'Ef� PREVENTl�N �'FZOG�AM <br /> � IIVVOl�� �O�T' �F�E/�i°CD�IiVN <br /> Please use this lnvoice Cost Breakciown as a temp3ate for invoices submitted as part of the Backwater <br /> Prevention Device rebate program. Either this form or your own invoice form with the foliawing Iine items can <br /> be submitteci. This allows you to invoice your client according to your existing billing templa#e vvhile aflowing <br /> city staff to identify haw costs eligible for tfi�e Backwater�revention Device Rebate were accrued_ <br /> Only labor and maferials direc#ly related to the installation and function of a backwater prevention <br /> device are eligible for Crfy rebate and fherefore should be included on the upper half of fhis form. <br /> Addrtional costs may be added to bottom of the form. ��� <br /> ��-��a ' '�_ <br /> Busines5 Name:.��"�r��.�� `�'��-�-L►cense Number: <br /> Business Maifing Address: ��-�r-% ��f�� ��' �'-.T-�'f���� '�"�'� ��'�����_� <br /> City State Z�p <br /> .� � .:�, Email � ��1r � F.�_5���-f��'��r� �;'r��S�._t�'�: �°�� <br /> Phone:�.� �IC� �;�''-� =1��?�"'a'"i� z ��—_ <br /> Cate o Descri tion Units Q anti Rate Total <br /> Administrafiion Administration I management Hours � ' `J "' L �' _ <br /> Labor CCTV Inspectioa Hours _ <br /> gWV Ins#alk Hours = <br /> Pipe replacement Hours _ <br /> Surface restoration Hours <br /> Site cleanup Hours <br /> Downspouts/drainage imp. Hours <br /> Materials Backwatervalve Pes Unit <br /> Grinder pump Per llnit <br /> 5ide sewer pipe(up to 8 feet) Fest <br /> Impor#ed Backfill Yards <br /> Surface Restoration Materials Lump <br /> top soil, rass seed, concrete, etc. sum ' <br /> Caver(irrigation box or Ioad bearing Per Unit <br /> cover <br /> Rentals Specify equipment Hour <br /> l � �� <br /> Fees Disposal fees by item Yards <br /> Delivery fees if not covered by labor <br /> Eli ible Total � <br /> Other Cos�.s Costs nat associated with BWD, antl <br /> not e!i ible for rebate detail below <br /> � � <br /> f � <br /> ,- <br /> `_ � - <br /> ineligible Total r'�' $ <br /> 7otal __ � <br /> Revised 9/03/2014 <br />