Download Form I — APPLICATION FOR ADMISSIBILITY

Form I — APPLICATION FOR ADMISSIBILITY
ENERGY EFFICIENCY: IMPLEMENTATION INCENTIVES PROGRAM
Section 1 – Customer identification
* Mandatory fields
ADDRESS OF PROJECT* FACILITIES AND CUSTOMER IDENTIFICATION
Location of facilities
* Name of company:
* Gaz Métro Account No.:
-
New building
-
* Québec enterprise number (NEQ)(Enterprise Register):
* Service address:
* Municipality:
* Postal code: * Contact person:
* Title:
Building’s owner:
* Postal address:
* Tel.:
Fax: * E-mail:
* Financial assistance should be sent to:
billing address or
Communications requested by mail or
address of contact person
Communications requested by e-mail**
* If the facilities or buildings have different Gaz Métro account numbers, submit a separate request for financial assistance for each Gaz Métro account number.
** Communications may include personal information in the legal sense of the word.
IDENTIFICATION OF FIRM/ENGINEER
* Name of company:
* Person responsible (or measures analyzed by):
* OIQ No.: * Postal address: * Tel.:
Fax: * E-mail:
Section 2 – Description of the building, energy systems and consumption
DESCRIPTION OF ENERGY SYSTEMS
TYPE OF SYSTEM
CONSUMPTION
ENERGY SOURCE >
(INDICATE CODE)
Domestic hot water:
Process:
† A simulated reference base may only be used for an energy simulation.
REFERENCE BASE = 12 MONTHS’ CONSUMPTION
to Units
Electricity:
kWh
Oil:
litres
Natural gas:
m3
Dual energy:
Other:
reference base†
E .......... electricity
O ......... oil
DE ....... dual energy (specify)
P . ........ propane
NG ...... natural gas
O ......... other (specify)
Ventilation:
source
........ Simulated
Code
Heating:
Period from energy
Quantity
........ Actual
or
Form IIb — REQUEST FOR FINANCIAL ASSISTANCE
ENERGY EFFICIENCY: IMPLEMENTATION INCENTIVES PROGRAM
* Mandatory fields
IMPLEMENTATION INCENTIVES
The undersigned, the customer, hereby wishes to advise Gaz Métro of his intention to implement the energy efficiency measure(s)
described in the “Summary of measures covered by request for financial assistance” (Form III) that accompanies this request.
The customer also includes with this request a complete copy of the Feasibility Study1, which describes the measure
covered by the eligibility application, as well as all the calculation papers that help establish the energy savings,
signed by the engineer in charge.
The customer acknowledges having received and read a copy of the admissibility criteria and all the conditions of
the program, as described in the Participant’s Guide, and confirms that he has complied with all the said conditions.
The customer would first like Gaz Métro to approve his admissibility for the Implementation Incentives Programs.
The customer hereby authorizes Gaz Métro’s designated representative to perform an onsite inspection of the
implementation and compliance of the measures covered by the financial assistance received from Gaz Métro.
The customer acknowledges that this inspection made be made at anytime within two working days’s notice.
1. Except for the studies covered by Gaz Métro’s Feasibility Studies Program.
The customer declares that the information provided
in all the documents submitted in connection with
his participation in these programs is accurate and
complete. The customer agrees that Gaz Métro may
check with other organizations likely to be participating financially in this project and to share information
with them. The customer acknowledges that any false
declaration may lead to a full repayment of the financial
assistance paid by Gaz Métro.
* Has the work been completed?
Yes
No
* Name of customer’s company:
* Name of customer’s contact person:
* Title
* Date:
(day / month / year)
Form III — SUMMARY OF MEASURES COVERED BY THE REQUEST FOR FINANCIAL ASSISTANCE
- Preliminary Version (after the work)
energyeFFiciency:iMPLeMentationincentiVesPrograM
Reserved for use by Gaz Métro
Price of natural gas
Average of the last 12 months: __________$/m3
Description of the measure or scenario, with reference to
the number of the measure, as shown in the feasibility study
PE N
Please complete the blank boxes outlined in blue
Useful
life
Intended
final use1
Energy
source
Energy unit
of measure
(kWh, m3
or litres)
o
Annual
consumption
of measure before
implementation
(baseline)
* Mandatory fields
Annual
savings
(m3)
Annual
savings3 ($)
Costs of
measure2 ($)
Payback
period3
DATECH
Total
1- Specify intended final use of measure: process, combined, space heating, domestic hot water.
2- Costs of acquisition, installation, removal, etc.
3- Simple payback period, excluding variations in energy prices.
Customer authorization:
I hereby authorize Gaz Métro to use the information in this report for monitoring and evaluation
purposes. This information will remain strictly confidential.
Validation by engineer:
I certify that the calculations of energy savings are accurate and that the measures studied and/or
implemented comply with the laws and regulations applicable in Québec.
* Name of customer’s company:
* Validation conducted by:
* Name of customer’s contact person:
* Name of firm:
* Date:
(day /month /year)
* Title:
* Date:
(day/month/year)
* Gaz Métro Account No:
-
By e-mail:
[email protected]
SEND
-
By mail:
Energy Efficiency Programs
Gaz Métro
1717 du Havre
Montréal (Québec) H2K 2X3
By fax:
514 598-3700
PRINT
* OIQ no: