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[ <br /> BACK1AfATER PREVENTION PROGRAM <br /> INVOICE COST 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 I <br /> be submitted.This allows you to invoice your client according to your existing billing template while allowing I <br /> city staff to identify how costs eligible for the Backwater Prevention Device Rebate were accrued. 1 <br /> , <br /> Onlylabor 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 1 f aA.a for ,,,, <br /> Additional costs may be added to bottom of the form /9/7- 0 6// 1,.. <br /> , A . <br /> Business Name: At+ piaiii tolitt c _License Number ifir**111"Filfalris," <br /> ,,, R <br /> P) 5 jo „ .. , i. , <br /> Business Mailing Address: Iiii In i Ar ' /W.. / Allg 2 ala I <br /> Phone: -- <br /> 4z-s----489oiri:5Eml: <br /> . mg-ipit444119 c • , (,_ <br /> Category Description Units , Quantity Total <br /> Administration Administration!management Hours <br /> Labor CON Inspection Hours i <br /> BVVV Install Hours i (-451) <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 <br /> Imported Backfill Yards <br /> Surface Restoration Materials Lump <br /> (top soil,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 /> Eligible Total $ <br /> Costs not associated with BVVD,and <br /> . Othe•r Costs not eligible for rebate(detail below) <br /> 10 --11 .,U - <br /> I <br /> Ineligible Total $ <br /> APIONIIINIV <br /> Total $ <br /> Revised 9/03/2014 <br />