Small Commercial Lighting Program Application Rebate Pre-approval Form by qpeoru8364

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									           Small Commercial Lighting Program Application                                                                                       CMLP Use Only



                                 Rebate Pre-approval Form
                                    Rate Schedule G-1 Facilities Only
          All Projects Must Be Pre-approved Prior To Commencement Of Work
          Concord Light will provide a rebate of 70% equipment and installation for eligible measures up to $2,000
          All 4' T8 lamps and Electronic Ballasts must be listed in the Consortium for Energy Efficiency as "qualifying."
          Lists of all qualifying lamps and ballasts can be found on CEE's website: http://www.cee1.org/com/com-lt/com-lt-main.php3 .

Project / Facility Information
    Project Name:                                                                 Electric Account #:
  Project Address:
  On-site Contact - Name & Title:                                                 Phone #:                                 Email or Fax #:
 Hours of Operation:                         Will building permit or major remodel be part of this project?    Yes:                      No:
 Project Comments:

Customer Information                        Check here if Customer Info is the same as Project Info and skip to next section.
 Electric Customer's Name:
Complete Mailing Address:
Contact Name:                                                       Phone #:                                   Fax #:
Email Address:
Send PSE pre-approval letter to:             Name:                                  Address:
Installation Information
Project materials to be installed by (check one box):      Lighting / Electrical Contractor:                  In-house Personnel:
  Contractor/Vendor's business name:                                             Contact Name:                                      Phone #:
   Disposal of hazardous lighting waste will be performed by:      Contractor                       Vendor               Customer
 Proof of proper lighting waste disposal shall include the CMLP Lighting Waste Disposal Form

Estimated Cost of Project                      $0                                                                                                                  2/11/09

Estimated Peak kW savings                      $0                           Estimated kWh Savings per year                  0


Rebate Will Be Issued in the Form of a Bill Credit Unless Other Advance Arrangements Are Made and Approved by CMLP
                                                                                                                                                               Page 1 of 4




        Concord Municipal Light Plant
How To Participate:

Step 1. Obtain CMLP Pre-Approval                                     Project Name:         0                                     Acct #: 0

           Check to make sure pages 1 thru 4 of this application are complete        (pages 1 thru 4 constitute application)
           Keep a copy for your records
           Keep a copy of the Lighting Waste Disposal form, which you will need to fill out and submit before rebate is approved
           Please ensure the printed name at bottom of this page is legible and signature is present before faxing or mailing
           Mail your completed and signed 4-page application to:                     Concord Light
                                                                                     Small Commercial Lighting Rebate Application
              Or Fax this application, with cover, to:     978-318-3105              PO Box 1029
                                                                                     Concord, MA 01742-1029


    When Pre-approved, Concord Light will notify customer via email/fax or mail.

Step 2. Complete installation within 90 days of notice of pre-approval.
                   If a delay becomes apparent, please contact CMLP at 978-318-3101.

Step 3. Submit completion paperwork for payment

           Initial and date the contractor's "itemized" invoice(s) to indicate your approval and acceptance of the installation.
           "In-house" installations - Please circle, or distinctly identify, each line on vendor's receipt that applies to this lighting project.
           Send a copy of the pre-approved pages you received from CMLP, signed and dated copies of all invoices and/or receipts, the disposal company's
           Hazardous Waste "Bill of Lading," and CMLP's "Lighting Waste Disposal form" (attached).
           Please allow four to six weeks for processing.

                                              Program guidelines and additional information can be found at:
                                                                www.concordma.gov/cmlp

Customer Agreement - Signature Required

         By signing below, customer agrees to comply with all applicable State and Local electrical code and permitting requirements and also the
         Small Commercial Lighting Rebate "Guidelines and Recommendations." Customer agrees to properly dispose of all lighting project lamp and ballast
         hazardous waste in accordance with local laws and CMLP's program requirements. Customer is solely responsible for determining adequate lighting
         levels and timely payment of contractors and/or vendors. CMLP, at its option, will be granted access to inspect the lighting system prior to, during
         and after this proposed lighting retrofit. Customer agrees to the existing and proposed lighting as being accurately described on pages 3 and 4 of
         this application. Concord Light has not and does not make any promise, warranty or representation with respect to any savings in energy
         consumption from Conservation Measure(s).

           Customer Signature:                                                                                         Date:

             Please Print Name:

       Concord Municipal Light Plant
                                Page 2 of 4




Concord Municipal Light Plant
                      SMALL COMMERCIAL LIGHTING REBATE                                               CMLP Electric Account #:                      0
                                                                                                     Project / Business Name:                      0
                            Rate Schedule G-1 Facilities Only

           All 4' T8 lamps and Electronic Ballasts, including lamps and ballasts contained within a new fluorescent lighting fixture, proposed for
           installation on this project shall be designated "High Performance" or "Reduced Wattage" by the Consortium for Energy Efficiency (CEE).
           Lists of all "Qualifying" lamps and ballasts can be found on CEE's website at: http://www.cee1.org/com/com-lt/com-lt-main.php3

                                                                                     ed
                                                                                                             Existing   Proposed    Annual
         ting                                                                  pos
                                                                                                   Fixture                                      kWh         kWh        kWh
                         Eligible Rebate Measures
    Exis
                                                                                                             Fixture     Fixture   Hours per                                   kW Saved
                                                                           Pro                                                                 Existing   Proposed    Saved
                                                                                                   Count
                                                                                                              Watts       Watts     Fixture
 Section I: INCANDESCENT BULB, FIXTURE & EXIT SIGN REPLACEMENTS
                                          Screw-in CFL, less than 26 watts
a. Incandescent screw-in bulb, any wattage
                                                Energy Star Listed                                                                                0          0           0         0.00
b. Incandescent screw-in bulb,            Screw-in CFL, 26 to 40 watts
     75 watts or greater                        Energy Star Listed                                                                                0          0           0         0.00
c. Incandescent screw-in bulb,            Screw-in CFL, greater than 40 watts
     150 watts or greater                       Energy Star Listed                                                                                0          0           0         0.00
d. Incandescent fixture,                  New CFL fixture or hardwired kit with
     100 watts or less combined               replaceable lamp, 25 total input watts or less                                                      0          0           0         0.00
e. Incandescent fixture,                  New CFL fixture or hardwired kit with
     100 watts or greater combined           replaceable lamp, 26 total input watts or more                                                       0          0           0         0.00
f. Incandescent fixture,                  New Linear fluorescent fixture, one or two-Lamp
     120 watts or greater combined              and one electronic ballast                                                                        0          0           0         0.00
                                          New LED Exit Sign (not kit) Energy Star listed
g. Exit Sign: Incandescent or CFL lamp(s)
                                            **Find listed Exit Signs at: www.energystar.gov                                                       0          0           0         0.00
 Section II: HIGHER WATTAGE INCANDESCENT & "HIGH INTENSITY DISCHARGE" FIXTURE REPLACEMENTS
a. Incandescent or Mercury Vapor fixture     New "HID" Fixture ("high intensity discharge"): HPS
    greater than 175 input watts             or MH (50-100W).                                                                                     0          0           0         0.00
b. "High Intensity Discharge" fixture        Pulse Start Metal Halide - Must have greater than
    Primarily Metal Halide                   25% input wattage reduction.                                                                         0          0           0         0.00
c. "High Intensity Discharge" fixture
                                             New CFL fixture greater than 40 input watts
    greater than 100 input watts                                                                                                                  0          0           0         0.00
d. "High Intensity Discharge" fixture
                                             New CFL fixture greater than 80 input watts
    greater than 175 input watts                                                                                                                  0          0           0         0.00
e. Incandescent or "HID" fixture             New Four-lamp F32T8 fixture with reflector and
    greater than 175 input watts             electronic ballast(s).                                                                               0          0           0         0.00
f. "High Intensity Discharge" fixture        New Six-Lamp F32T8 fixture with electronic
    Greater than 400 input watts             ballasts.                                                                                            0          0           0         0.00
g. "High Intensity Discharge" fixture        New Four-Lamp F54T5HO fixture with electronic
    Greater than 400 input watts             ballast(s).                                                                                          0          0           0         0.00
                                                                                                     0          0                  Totals = #VALUE!       #VALUE!    #VALUE! #VALUE!
                                                                                                                                                kWh         kWh        kWh
                                                                                                                                                                               kW Saved
CMLP Pre-approval: Authorized Signature ________________________________________ Date ________________                                         Existing   Proposed    Saved
                                                                                                                                                                     Page 3 of 4
                                                                                                               CMLP Electric Account #:                          0
                           SMALL BUSINESS LIGHTING REBATE                                                       Project / Business Name:                         0
                                Rate Schedule G-1 Facilities Only

            All 4' T8 lamps and Electronic Ballasts, including lamps and ballasts contained within a new fluorescent lighting fixture, proposed for
            installation on this project shall be designated as "High Performance" or "Reduced Wattage" by the Consortium for Energy Efficiency (CEE).
            Lists of all "Qualifying" lamps and ballasts can be found on CEE's website at: http://www.cee1.org/com/com-lt/com-lt-main.php3

                                                                                      sed
                                                                                                                       Existing    Proposed    Annual
         ting
                                                                                                             Fixture                                       kWh         kWh
                           Eligible Rebate Measures
     Exis                                                                         ropo
                                                                                                                       Fixture      Fixture   Hours per                         kWh Saved     kW Saved
                                                                                                             Count                                        Existing   Proposed
                                                                                P                                       Watts        Watts     Fixture
 Section III: 4' & 8' FLUORESCENT - "High Perfomance" Lamps & Ballast Retrofits Only
a. F40 T12, One or two-lamp fixture with    "Lamp-for-lamp": F32T8 lamp(s). Low Ballast Factor
           one magnetic ballast             ballast required.                                                                                                0          0           0           0.00
b. F40 T12, Three or four-lamp fixture with "Lamp-for-lamp": F32T8 lamps. Low Ballast Factor ballast
           two magnetic ballasts            required.                                                                                                        0          0           0           0.00
c. F40 T12, Four-lamp fixture with two      Reduce lamps to Two F32T8 lamps and one electronic
           magnetic ballasts                ballast.                                                                                                         0          0           0           0.00
 Section IV: 4' & 8' FLUORESCENT - New Linear "High Performance" T8 Fixtures & Conversion Kits (NRTL-listed)
a. F40 T12, One or two-lamp fixture,               One or Two F32T8 lamp(s). Low Ballast Factor       Kit                                                    0          0           0           0.00
            one magnetic ballast                   required                                           New                                                    0          0           0           0.00
b. F40 T12, Three or four-lamp fixture,            Lamps reduced to two or three F32T8                Kit                                                    0          0           0           0.00
            magnetic ballasts                      "Low Ballast Factor" ballast recommended           New                                                    0          0           0           0.00
c. F96 T12, One lamp fixture,                      Two F32T8 lamps and one electronic ballast. "Low   Kit                                                    0          0           0           0.00
            one magnetic ballast                   Ballast Factor" ballast required                   New                                                    0          0           0           0.00
d. F96 T12, Two lamp fixture,                                                                         Kit                                                    0          0           0           0.00
                                                   Two F32T8 lamps and one electronic ballast.
            one magnetic ballast                                                                      New                                                    0          0           0           0.00
e. F96 T12, Two lamp fixture, one                  Four F32T8 lamps and one electronic ballast. "Low Kit                                                     0          0           0           0.00
            magnetic ballast                       Ballast Factor" ballast required                  New                                                     0          0           0           0.00
f. F96 T12 HO, Two lamp high-output                                                                   Kit                                                    0          0           0           0.00
                                                   Four F32T8 lamps and electronic ballast.
            fixture, one magnetic ballast                                                             New                                                    0          0           0           0.00
g. F96 T12 HO, Two-lamp high-output                Four F32T8 lamps with reflector and one electronic Kit                                                    0          0           0           0.00
           fixture, one magnetic ballast           ballast                                            New                                                    0          0           0           0.00
 Custom      "Custom"                  Describe:                                                                                                             0          0           0           0.00
 Analysis    total cost                Describe:                                                                                                             0          0           0           0.00

                                                                                                                                              Totals = #VALUE!       #VALUE!     #VALUE!      #VALUE!
                                                                                                                       Conncted                 Post
                                                                                                                                                           kWh         kWh
      Lighting Controls                                                                                     Quantity     Load /
                                                                                                                        Wattage
                                                                                                                                Pre-Control
                                                                                                                                  Hours
                                                                                                                                               Control
                                                                                                                                               Hours
                                                                                                                                                          Existing   Proposed
                                                                                                                                                                                kWh Saved
                                                                                                                                                                                                Use
                                                                                                                                                                                              Reduction

1. Occupancy Sensor (incl. fixture mounted ) or Timer Control            Controlling 100W to 199W:                                                           0          0           0         #DIV/0!
2. Occupancy Sensor (incl. fixture mounted ) or Timer Control            Controlling 200W or more:                                                           0          0           0         #DIV/0!
                                                                                                               0                  PROJECT TOTALS = #VALUE!           #VALUE!     #VALUE!      #VALUE!
                                                                                                                                                           kWh         kWh
                                                                                                                                                                                kWh Saved     kW Saved
CMLP Pre-approval: Authorized Signature ___________________________________ Date _______________                                                          Existing   Proposed
                                                                                                                                                                                Page 4 of 4
                        Small Business Lighting Rebate Program
                                   Project Summary




02/11/09




RE:   Lighting Retrofit at:   0


Cost:

Contractor's proposed total bid price for this project:    $0.00    (materials, labor, tax etc.)

Your estimated CMLP Rebate for this project:               $0.00

Your estimated project cost after the CMLP Rebate:         $0.00



Savings:

Your estimated electrical energy savings:                 #VALUE!   kWh per year

Your estimated electrical cost savings:                   #VALUE!   per year




Financial Analysis:

Your payback for this project including CMLP rebate:      #VALUE!   years

The payback for this project excluding CMLP rebate:       #VALUE!   years
             Concord Municipal Light Plant

                                                       Lighting Waste Disposal Form
                      Instructions to CMLP customer and installing contractor: Please read, fill in, and sign at the bottom.

This form documents how lighting waste will be properly disposed of by CMLP business customers participating in the Small Commercial Lighting Rebate program. Suitable
documentation is provided through: 1) accurate counts, and 2) evidence that the installer practices proper disposal of lighting waste. When handing off waste to an approved
recycler, secure a Waste Disposal Certificate from the approved lighting waste recycler. Or, as an alternative to a certificate, obtain a receipt issued by a government agency
that transfers waste to a suitable recycler. Provide a copy of the “certificate” or receipt as back-up for this form.



Customer: 0                                                        Elec. Acct #:       0                                   Installer:   0



1. Lamp and Ballast Disposal

Number of LAMPS disposed of: 4-FT ______             8-FT _______ Mercury Vapor _______ Metal Halide_______ HPS _______

Number of BALLASTS without “no PCBs” on the ballast’s label: _________ (Note: All ballasts that may have PCBs must be documented and disposed of by
an approved recycler.)

Name and location of recycler or authorized handler: _________________________________

2. Authorized Signatures

I certify that the above information is true and accurate. All lamps and ballasts from this project will be disposed of in accordance with applicable federal, state
and local waste disposal regulations.

1. Lighting Installer or Vendor:                                2. CMLP Customer:

                                                                                                                              Thank you for including a copy of your
                                                                                                                              recycler’s Certificate of Disposal.
   Date:                                                         Date:

								
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