EnergySmart – Round 3 – 2012 » app1

Application

Part 1 of 5: Customer and Contractor Information

Use the Next/Back buttons at the bottom of each form to navigate the application.
Business Customer Information
(Where the equipment is installed)
Company*
Parcel number*
If you need help finding your Parcel number see the Assessor's website
Site address*
Suite No.
City*
State*
Zip*
Business Type (please select one)*
 Restaurant
 Grocery Store
 Liquor Store
 Lodging/Accommodation
 Auto Body/Repair
 Retail (including auto sales)
 Office Building
 Medical Office (including dental and veterinary)
 Manufacturing
 Dry Cleaner/Laundromat
 Religious Worship
 Multi-Family Units
 Educational Buildings
 Other
Affected by Installation Square Footage*
(Applies to lighting, HVAC and Building Envelope measures)
Does the business customer own or lease the property?*
Owns
Leases
If the property is leased please provide the following information for the owner.
Owner's name**
Address**
City**
 State**
 Zip**
Tel**
Contact Person
Name*
Title*
Email*
Tel*
Fax
Mailing address (if different)
City
 State
 Zip
Contractor information
Company name*
Address*
City*
 State*
 Zip*
Tel*
Fax
Email*
Select all that apply:*
 Association of Energy Engineers (AEE)
 Building Performance Institute (BPI)
 Commercial Energy Services Network (COMNET)
 DOE/ITP Specialist
 Residential Energy Services Network (RESNET)
 North American Technical Excellence (NATE)
 American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE)
 Other:

 None of the above
Total number of contractors' labor and administrative hours worked on project.*
Utility Information: provide account information for meters most closely affected by the installation.
Electric Utility Provider*
Electric Customer Account Number*
Gas Utility Provider*
Gas Customer Account Number*
Does the facility use propane?
 Yes
Facility has (please check one):*
 Heated space only Air conditioned space
Payee Information
Name of person or business that the rebate check should be made payable to. Must be the business or property owner Participant. May not be contractor:*
Mailing address*
City*
State*
Zip*
Contact Name*
Contact Email*
Tel*
Fax

*Required Field

**Required Field If Business Leases the Property