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, <br /> I <br /> , <br /> BACKWATER PREVENTION PROGRAM <br /> ,viorwY- INVOICE COST BREAKDOWN <br /> i <br /> Please use this Invoice.Cost Breakdown as a template 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 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 inclucfed on the upper half of this form, <br /> Additional costs may be added to bottom of the-form. A-604 bli PD* <br /> , <br /> Business Name: ri--,0- i.1) VIVI 11 V't O. C . License Number: 4A-- plivviLivt. d.r. \.‘, L <br /> k <br /> „, ,,, <br /> Business Mailing Address: 1 S44-frAMPI <br /> t -,,,.11,,,,e4;6.47- /AM- 77 LOS,... V <br /> city Stptt Zip <br /> 2,,s— 9aif23 <br /> _ , <br /> Phone: .----.... . .... Email: . 4 <br /> , 1 <br /> Category Description Units Quantity Rate Total <br /> 1 <br /> Administration Administration/management Hours r <br /> Labor - CCW Inspection , -Hours <br /> 4.----- <br /> BWV Install Hours ) i/co <br /> 4„.„...-- Pipe replacement Hours 8 4C I-) <br /> , t - <br /> Surface restoration Hours 3(mac a)rcei <br /> Site cleanup ; Hours ' 91,0- - <br /> D,.. <br /> - , I • .1 ., r , - <br /> CioweispCuts rcirainagb kinp. Hours <br /> . ,.. , <br /> Materials Backwater valve Per Unit <br /> Grinder pump Per Unit <br /> Side sewer pipe(up to 8 feet) Feet r <br /> Imported Backfill Yards <br /> i <br /> Surface Restoration Materials Lump <br /> (top soil,grass seed,concrete,etc.) sum 9 0 i <br /> Cover(irrigation box or load bearing Per Unit <br /> cover) <br /> v <br /> 1 <br /> Rentals * Specify,equipment Hour ; <br /> Fees Disposal fees by item Yards <br /> Delivery fees if not covered by labor <br /> Eligible Total :' $ <br /> Other Costs Costs not associated with BWD,and <br /> not eligible for rebate(detail below) <br /> ,. .. . <br /> erro-OC- Iii tvt Vrtu4), <br /> 1-44-2k- — *'. .0*"'-"+"°- ----- <br /> Ineligible Total $ <br /> Total $"*. c-C1—‘ <br /> Revised'9t03/2014 <br />