Homeowner Incentives for Energy Efficient Repairs and Renovations

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1 Instructions 1) Contact at ReBuild Western MA at or by 2/15/2012 to prequalify 2) Complete and submit a completed application, including the signed acceptance on page 4, with all required documentation via one of the options listed: Mail: ReBuild WMA c/o ICF Fax : Hayden Ave, 3 rd Floor Lexington, MA ) You will receive a participation confirmation letter outlining the incentives you may be eligible to receive. Final incentives are subject to verification. 4) Following final reporting/inspection, designated recipient will receive incentive check(s) for all qualified home units. Applicant (Property owner): PROJECT AND INCENTIVE RECIPIENT INFORMATION Recipient (incentive check issued to, if not homeowner): FEMA Registration #: Relationship to Property Owner: Site Address: Street or PO Box, City, & Zip Code: Recipient Address: Street or PO Box, City, & Zip Code: Phone: Phone: If recipient is different than applicant, applicant must sign to authorize: PROJECT INFORMATION Please circle your primary home heating Fuel Type: Natural Gas Electric Oil Propane Other Gas Service Provider (if applicable): Natural Gas Account #(if applicable): Electric Service Provider: Electric Account #: Are you currently participating in the Utility funded Western MA Storm Recovery Programs: Yes No If no, would you like to learn more about these Programs: Yes No Does this property include any Low Income Units: Yes No Number of Low Income Units: Number of Non Low Income Units: Low Income Documentation: Building Permit Number: Town Energy Code: Base Stretch Unsure General Contractor/Builder or Architect: General Contractor/Builder or Architect - address: General Contractor/Builder or Architect Mailing address 1

2 SUB-CONTRACTOR INFORMATION (if applicable): Company Insulation and air sealing Contact Address Phone Windows and Doors Heating System Cooling System Domestic Hot Water Heater HOMEOWNER REPAIR AND RENOVATION GRANT INCENTIVES Envelope Incentives Note: These Envelope incentives require signed certification from a HERS rater stating that the rebates claimed are for eligible equipment that is newly installed in an eligible tornado-affected home. Additional Low Income funding is available for repairs. Doors & Windows Windows U-value of 0.28 or less Outside Doors Energy Star 5.0 # of Windows/Doors Incentive available per unit Building Insulation Area(s) insulated Incentive available (up to 100%) Attic (at least R-38) Walls (at least R-20) Basement (at least R- 10/13) Floors (at least R-30 Low Income adder per unit $200 $100 $100 $50 Low Income adder per unit (up to 100%) $2,000 $2,000 $ Total Envelope Incentives Requested: $ $ $ Total Dollar Amount Requested Total Dollar Amount Requested 2

3 HOMEOWNER REPAIR AND RENOVATION GRANT INCENTIVES- EQUIPMENT (High Efficiency Heating, Ventilation and Air Conditioning Equipment) Equipment Incentives Note: Equipment incentives require either signed certification from a HERS rater or receipts from contractors stating that the rebates claimed are for eligible equipment below that is newly installed in an eligible tornado-affected home. Rebate Specs Manufacturer Model # # Installed Incentive Available Low Income adder Heat Recovery Ventilator Total Dollar Amount Requested 1 Central Air Conditioning Equipment SEER >16 EER > 13.0 TXV or EXV required Ductless Mini-split Systems SEER >14.5 EER > 12 HSPF > 8.2 TXV or EXV required Heating Oil Boiler AFUE > 86% $1,000 $500 $ Heating Oil Furnace AFUE > 86% $800 $400 $ Natural Gas Furnace ECM 1 AFUE >96% $800 $400 $ Natural Gas Hot Water Boilers Natural Gas Condensing Boiler with On-Demand Domestic Hot Water 2 High Efficiency Indirect Water Heater Natural Gas Condensing Gas Water Heater Natural Gas On-Demand, Tank-less Water Heater AFUE > 96% AFUE > 90% Attached to natural gas boiler 94% thermal efficiency or greater (75 to 300 MBH) >.95 EF with Electric Ignition $1,500 $750 $ $1,600 $800 $ $400 $200 $ $800 $400 $ TOTAL ENVELOPE INCENTIVES (From Page 2) $ TOTAL INCENTIVES (Cannot Exceed $5,000 per Unit) $ If Applicable, HERS Rating Company: Rater: Date: 1 Total dollar amount requested is the number of installed measures times the rebate amount (including the low income adder). 2 Must be considered one unit by manufacturer 3

4 ReBuild Western Massachusetts Terms and Conditions 1. Definitions 2. Eligibility 3. Installation 4. Warranties a. DOER refers to the Massachusetts Department of Energy Resources b. Program refers to the ReBuild Western MA Energy Efficiency Program c. EEOs are the energy efficiency opportunities described in the ReBuild Western Massachusetts forms a. Residents, businesses, and municipals repairing or rebuilding their facility as a result of damage incurred from the June 1, 2011 tornado are eligible to participate. Residents, businesses, and municipals are required to provide documentation verifying the repair or construction is a result of tornado damage. b. Participants can participate in only one of the following programs: the Complete ReBuild, Major Renovations, or Repairs Program. c. Repairs, construction, and installations must be completed April 30, d. When required by law, repairs, construction, installations, and engineering services must be completed by a licensed contractor. e. Residents, businesses, and municipals must send and complete all forms and any other required documentation to the DOER no later than thirty (30) days after install. f. All incentive forms in connection with the Program must be received by the DOER by April 20, 2012 a. Prior to honoring any incentive, the DOER reserves the right to conduct and on-site verification that the EEOs were installed according to Program guidelines and is in operation. This site visit and all aspects related to this site visit, and conducted solely for such purpose. The site visit is not a safety review, nor is it intended for any other purpose. a. The DOER and the Program Administrator do not endorse, guarantee, or warrant any particular engineer, contactor, manufacturer, or installation. 5. Changes to the Program 6. Tax Liability a. Program is subject to change without prior notice, and incentive offers may increase or decrease at any time. a. Participants of the Program may be subject to tax liability for the values of the goods and services received through the program pursuant state or federal income tax codes. 7. No Tax Liability or the DOER or the Program Administrator a. The DOER and the program administrator are not responsible for any tax liability which may be imposed as a result of the receipt of the rebates provided by the DOER to the customer. 8. Liability & Release 4

5 a. As part of the consideration for participating in the Program, participant hereby releases and shall indemnify, hold harmless, and defend the DOER and it s Program Administrator from any and all claims, losses, harm, costs, liabilities, damages, and expenses (including attorneys fees) of any nature whatsoever arising directly or indirectly out of or in connection with the installation the EEOs at the premises or any material and labor required for such installation. Applicant Signature: Date: Submit this completed and signed application along with required documentation via one of the following: Fax : Mail: ReBuild WMA c/o ICF 33 Hayden Ave, 3 rd Floor Lexington, MA

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