Fillable Contractor Invoice Form printable pdf download

Contractor Invoice Form

To be completed and signed by the General Contractor. All applicable fields are required for approval.

Official Use Only: Project ID

Incomplete forms or incorrect reporting will delay approval.

Homeowner Information

Homeowner Name:

Utility Name:

Site address:

Site City / State / ZIP code:

Installation Information

General Contractor Company Name:

Date of Installation:

Distributor Name:

Distributor branch location (City, State):

Retail Partnership:

Yes

No If yes, please specify retailer and provide Retail Invoice (Home Depot, etc.) _____________________________________

TOTAL installed cost, including: equipment, labor, electrical, tax, permit and other (

___________________________________

prior to rebate/discounts

Equipment cost: $__________

Labor cost: $__________

Electrical cost: $__________

Tax cost: $__________

Permit cost: $__________

Other cost: $__________

Total # of all outdoor units installed:

Total # of all indoor units installed:

__________

Which method was used to ensure the DHP functions as the

Thermostat(s) set back, DHP as primary

Furnace / zonal heater(s) off at breaker

primary heating system?

Furnace / zonal heater(s) off at thermostat(s)

Other

:__________________

(please explain)

Detailed Description of Outdoor Unit #1 Installed to Serve Main Living Area

Manufacturer Name:

Outdoor Unit #1 Model No.:

AHRI Certified Ref#:

HSPF#

Additional refrigerant added to

(Min: 9.0 single-zone & 8.0

multi-zone systems):

Outdoor unit #1:

(over manufacturer’s

pre-charge):____

oz.

Indoor unit(s) for

Indoor unit model number(s)

Zone square

Zone room

Installed line set length

Outdoor unit #1

for OUTDOOR UNIT #1 ONLY

footage

description

(ft

)

(ft)

Indoor Unit 1

(in main living area)

Unit 2

(if installed)

Unit 3

(if installed)

Unit 4

(if installed)

Description of Additional Outdoor Units (if installed, do not include Outdoor Unit #1 data):

ADDITIONAL OUTDOOR

Outdoor Unit #2 or 3

Zone room

AHRI Certified Ref#

Number of indoor units

UNITS ONLY

Model No.(s)

description(s)

Outdoor unit 2

(if installed)

Outdoor unit 3

(if installed)

General Contractor Signature Release

By signing below, the General Contractor/ installer certifies that this invoice form and all accompanying documents are complete and accurate. The signature certifies that the

General Contractor/Installer is licensed, bonded, insured, has been trained by the manufacturer of the installed product and has received NW Ductless Heat Pump Project

installer orientation. By signing this, the General Contractor/installer has read and understood the terms and conditions printed on the back of this form and/or Project

information on the NW Ductless Heat Pump Project website ( ).

Who is the best person to contact?

Email contact:

Employee Name (Installer) & Installing Company/Sub-Contractor:

Date:

Signature:

By checking this box you are providing

a signature and agreeing to the above terms.

(

)

(

)

Phone:

Work

Cell

Alternative phone:

Work

Cell

Yes, I have obtained a completed Homeowner Participation Form for this installation.

Yes, I have included a copy of the job sales invoice for proof of installation.

Yes, I have installed line hide (and UV tape as needed) on the entire length of exterior, insulated refrigerant lines (For details, see page 2.).

Yes, I have installed the system in accordance with Manufacturer specifications, and the NW Ductless Heat Pump Project Best Practices, including adherence to proper

refrigerant charging.

Yes, I have all required licenses, registrations, certifications and permits for the work performed at the site address on this form.

This form, subject to change, is effective from October 1, 2015.

Return completed form to:

DHP Services

100 SW Main St, Suite 1500  Portland, OR 97204

Phone 888.958.7472  E-mail: