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i <br /> #74,,,,C=Iri <br /> BACKWATER PREVENTION PROGRAM <br /> INVOICE COST BREAKDOWN <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 included on the upper half of this form. <br /> Additional costs may be added to bottom of the form. <br /> Business Name: A-6 f flL' 1 O1 -� 1 e License Number P -'1 * bi/ r 4 <br /> Business Mailing Address: Cf% �� `� M ;_ <br /> '_ t " ' 1 t 7 { 9r2-68 <br /> Phone: ',��_ Li tretn fi ��;�U1'ts�te� 64k (Ali' <br /> Category Description Units Quantity Rat Total <br /> Administration Administration I management Hours <br /> Labor CCTV Inspection Hours - �; <br /> BWV Install Hours r'!L <br /> Pipe replacement Hours / 5 1) <br /> Surface restoration Hours / <br /> Site cleanup Hours <br /> Downspouts/drainage imp. Hours <br /> Materials Backwater valve Per Unit / j 01 S V <br /> Grinder pump Per Unit <br /> Side sewer pipe(up to 8 feet) Feet <br /> Imported Backfill Yards / 11,5 <br /> Surface Restoration Materials Lump c <br /> (top soil, grass seed, concrete,etc.) sum / ''.)) <br /> Cover(irrigation box or load bearing Per Unit `` <br /> cover) / `5 <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 BWD,and <br /> Other Costs <br /> not eligible for rebate(detail below) <br /> Ineligible Total $ <br /> 1 I Lrte. (,.'t"' <br /> Total tt��-y"" <br /> Revised 9/03/2014 <br />