Source and Application of Funds Sample - PDF by bmo28403


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									             APPENDIX A:



CREATED BY VPA & VSA as an example only
Please fill out each section below, print and sign. Send one signed original and five
copies to the contact and address provided on the first page of the RFP. An electronic
copy may be emailed or submitted on a CD.
Project Category (Energy Efficiency Retrofits, Financial Incentive Programs, Implementation of
Transportation Projects, or Renewable Energy Technologies on Government Buildings):

Energy Efficiency Retrofits
Applicant Name: Sample School
Applicant Address:
2 Prospect Street, Montpelier, VT 05477

Primary Project Contact Name, Telephone, and email address: 802-229-0547
Estimated Total Project Cost: 57,202
Funds Requested: 50,000
NOTE: All projects must include a minimum 10% match from applicants (which can be
cash or in-kind) so you can not request more than 90% of the total project costs.

Source of match funds (Describe source of funds, including pending and projected funds. Describe
whether there is an outstanding request or a request yet to be made for any of the funds and the likelihood
of receiving the funds, including when you expect to hear on pending sources of requested funds):

Sample School has secured approval for the 10% in matching funds for this
project. Sources of funds are: $5,202 in-kind labor for oversight and project
management and $2,000 in capital reserve fund.

**If your match can be obtained from Efficiency Vermont prescriptive
forms, this works. Forms are at their rebate center:

Project Participants (Name and title of primary project personnel and their role in the project and their
qualifications/ experience relevant to the project. Also list subcontractors including firm name and address,
contact person, work to be subcontracted, and nature of subcontractor’s abilities.) :
John Smith, Sample School Business Manager, is the financial manager of
this project and will provide project oversight as well as track and report all
required metrics. John Smith has 15 years experience as the Sample
School business manager and supervised the $100,000 window
replacement project in 2005, which included adhering to National Historic
Preservation Act Guidelines.

Don Jones, facilities manager and a licensed electrician, will oversee all
onsite work by the subcontractors. Don Jones has been the Sample
School facilities manager for seven years and has supervised other
building projects, including the 2005 window replacement project. He is
BOC I & II certified.

Sample School will subcontract out all electrical work required for this
project and use the bid process. Sample School will require the
subcontractor be a licensed electrician in Vermont with experience working
in schools and with Davis-Bacon and all federal requirements associated
with this project.

Workplan/Project Description (Include list of tasks to complete project; project timeline, which
includes a start date and estimated completion date; quality assurance measures, including project oversight
and plan to track and report required metrics; and description of the financial management plan. Staff
member(s) that will be responsible for completion of the items above should be identified. Include date of
construction for each existing building and/or structure that will be physically affected by the proposed
project. Also describe the potential for public visibility and/or plan for promoting the site/project. Describe
why this project is important to your community):
The Sample School was built in 1945 and a comprehensive energy needs
assessment and plan was completed September 2008. The Sample school
has implemented this plan and replaced windows and the boiler system
over the last two years. This grant will allow us to continue our work and
replace existing T-12 fluorescent lights in 25 classrooms, hallways and
offices with high performance T-8 lamps, electronic ballasts and
occupancy sensors. As previously mentioned, John Smith, the business
manager, will be responsible for project oversight, including all federal
tracking and reporting of required metrics and the financial management
plan. Don Jones, facilities manager, will oversee all subcontractors onsite.

Task                                         Responsible Party                     Start*    End*
Preliminary Planning                         Town Energy                           3/01/2010 3/15/10
Committee review of grant                    Committee, Board
award and next steps                         Chair, Principal, John
                                             Smith, Don Jones
Bid development                              John Smith                            3/16/10          5/15/10
Bid Review                                                                         5/15/10          6/01/10
Accepting Bid                  Board Approval/Anne                                 6/01/10          6/15/10
Contract                       John Smith               6/15/10    6/30/10
Construction                   TBA- Bid process, Don 7/01/10       8/15/10
Commissioning                  Commissioning Agent      8/15/10    8/30/10
*All dates are subject to change based on grant award and bid process.

This project is important to the community because it will save the school
money, which impacts local taxes. The school will also serve as a model of
energy efficiency and the improved lighting will positively impact the
school environment. This project will be promoted to students, parents
and the larger community through an informational kiosk at the school, a
website energy improvement page tracking cost savings, the school
newsletter and integration into the school science curriculum at
appropriate levels.

Required Approvals for Project (Include description of any town or school approvals received to
date and any approvals yet required):

Anne Sanders, Board Chair, approved 11/23/2009
Wendy Scott, Superintendent, approved 12/1/2009
Ken Page, Executive Director, approved12/6/2009

Permitting (Include a list of all permitting requirements for the project and whether any of the permits
have been obtained):

The permit is a pro-forma endeavor for electrical work and the electrical
contractor will get a permit for this project. This will not delay the project.

Preliminary Planning/Project Development (Describe any planning or project development that
has already been completed for the project, such as an energy audit or feasibility study):

An Energy Audit was completed by the School Energy Management
Program September 2008 and a comprehensive plan was developed to
address the identified needs. An energy planning committee comprised of
the town energy committee, school board representative, principal and key
staff participated in the development of this plan and meet on a quarterly
basis. Over the last two years, Sample School has followed this plan and
replaced windows and the boiler system.

Name, title, phone, and email of Authorized Representative(s):
Ken Page, Executive Director, 802-229-0547, kpage@Sample

Signature of an Authorized Representative:
Date: 12/6/2009

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