Utility Name(Required) Homeowner Name(Required) Site Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Homeowner Phone Number(Required)Homeowner Email Address(Required) House / unity square footage(Required) If unknown, please estimateType of primary electric resistance heat in the home?(Required) Zonal Electric hydronic Furnace Which of the following describes the home?(Required) Detached single-family, duplex, triplex or fourplex Multifamily (5 units or more in a single structure) Manufactured home Zonal heating includes electric, non-ducted: ceiling cable, wall, baseboard, and an electric boiler/water heater attached to a zoned hydronic floor heating system. Homes with an electric forced air furnace, multifamily residences or manufactured homes may qualify for a utility incentive, but currently do not qualify for the Bonneville Power Administration (BPA) program. Please check with your electric utility for eligibility. To be eligible for incentive payment under the BPA program the home must have permanently installed zonal electric resistance heat as the primary heating system. A qualifying home cannot: (i) be new construction, (ii) have a fossil fuel central forced air or fossil fuel hydronic heating system, nor (iii) have a ducted heat pump system. The undersigned utility customer requests and authorizes the specified utility to release billing and usage information for the account listed below to the BPA or its agent. With this authorization, the BPA can request billing information for up to two years pre -installation and two years post-installation. The utility customer also hereby releases the utility company from any and all liability arising from or connected with providing this information. The homeowner also agrees to the terms and conditions listed on the back of this form. Account Holder Name(Required) Electric Utility Account Number(Required) Installation InformationContractor company name:(Required) Date of installation(Required) MM slash DD slash YYYY Total installed cost(Required) Including: equipment, labor, electrical, tax, permit and other (prior to rebate)Total number of outdoor units installed(Required) Total number of indoor units installed(Required) Outdoor unit manufacturer(Required) Outdoor unit model number(Required) AHRI certified reference #(Required) Associated Indoor unit 1(Required) Indoor unit 1 model number(Required) Associated Indoor unit 2 Indoor unit 2 model number Associated Indoor unit 3 Indoor unit 3 model number Associated Indoor unit 4 Indoor unit 4 model number Include a copy of the job sales invoice for proof of installation(Required) Drop files here or Select files Max. file size: 499 MB. This form, approved for use by BPA, April 1, 2012. Contractor Signature ReleaseBy signing below, the contractor certifies that this invoice form and all accompanying documents are complete and accurate. The signature certifies that the contractor is licensed, bonded, insured, has been trained by the manufacturer of the installed product and has received project contractor orientation. By signing this, the contractor has read and understood the terms and conditions listed on this form and/or project information on the NW Ductless Heat Pump Project website (https://www.GoingDuctless.com). Who is the best person to contact?(Required) Email Contact(Required) Installer Name(Required) Date(Required) MM slash DD slash YYYY Phone(Required)Work or Cell?(Required) Work Cell Consent(Required) Yes, I have included a copy of the job sales invoice for proof of installation.(Required)Consent(Required) Yes, I have installed refrigerant line protection on entire length of exterior, insulated refrigerant lines(Required)Consent(Required) Yes, I have installed the system in accordance with manufacturer specifications, including adherence to proper refrigerant charging.(Required)Consent(Required) Yes, I have all required licenses, registrations, certifications and permits for the work performed at the site address on this form.(Required)Terms and Conditions(Required) I agree to the Terms and ConditionsTerms and Conditions OFFICIAL FORM: This form and any required additional documentation, including installation invoice, must be filled out completely, truthfully, and accurately. Project details, including incentives, are subject to change without prior notice. HOMEOWNER ELIGIBILITY: To be eligible for incentive payment, the home must have permanently installed zonal electric resistance heat as the primary heating system. A qualifying home cannot: (i) be new construction, (ii) have a fossil fuel central forced air or fossil fuel hydronic heating system, nor (iii) have a ducted heat pump system. SYSTEM ELIGIBILITY: To be eligible for incentive payment, ductless heat pumps installed must be: a split system heat pump employing an inverter-driven, variable speed compressor, a variable speed outdoor fan, and a multi-speed or variable speed indoor blower. Additionally, indoor units using any type of field installed duct system are NOT eligible. CONTRACTOR ELIGIBILITY: Contractors must be licensed, bonded and insured, have successfully completed manufacturer sponsored training for equipment being installed and have attended an orientation provided by the NW Ductless Heat Pump Project (the Project) available at http://goingductless.com/partners/contractors. CONTRACTOR REMOVAL: Non-compliance with installation specifications and/or Quality Assurance Inspections may trigger a performance review of the installation contractor. This review will be conducted by the NW Ductless Heat Pump Project Quality Assurance team. The performance review may result in suspension or permanent removal from participation. Findings of the performance review will be communicated, in writing, to the installation contractor and participating utility along with terms of suspension or removal. VERIFICATION AND INSPECTION: Participating homes are subject to random onsite inspections in order to verify that installations meet Manufacturer specifications and that the home meets eligibility guidelines. You may be contacted by phone or email to schedule an inspection. No warranty is implied by this inspection. TAX LIABILITY: Neither the utility, BPA, nor the contractor is responsible for any tax liability, which may be imposed on the Participant as a result of payment of any incentives or as a result of obtaining financing. ENDORSEMENT: The NW Ductless Heat Pump Project does not endorse any particular manufacturer, contractor, or product in promoting ductless heat pumps. The fact that the names of particular manufacturers, contractors, or products may appear on Project materials does not constitute an endorsement. Manufacturers, contractors, or products not mentioned are not implied to be unsuitable or defective in any way. SAFETY AND BUILDING CODES: The Participant agrees to pursue compliance with federal, state, and local building and environmental codes for the installation of this product. The contractor certifies products have been installed consistent with manufacturer instructions. PROPERTY RIGHTS: The Participant must have proper authority to install the ductless heat pump system on the designated property or has obtained any necessary consent from the landlord. ACCESS AND EVALUATION: The Project and its representatives may request access to the property on which the ductless heat pump system was installed to review and evaluate the system during and after Project completion. The Participant agrees to provide reasonable access to the property for the purposes described herein. In addition, the project may contact the participant for survey participation and project feedback. REFRIGERANT LINE PROTECTION: At the time of installation, contractor must protect all exterior, insulated refrigerant lines. Protection is either UV resistant tape wrapped around insulated refrigerant lines or rigid line hides installed over insulated refrigerant lines. This form, approved for use by BPA, April 1, 2012.
