2017 Custom Incentive Application Step 1 of 2 50% Section A: CUSTOMER INFORMATIONCustomer Name * Required First Last Facility Address * Required Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is this the mailing address? * RequiredYesNoMailing Address * Required Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Electric Account Number * RequiredRate * RequiredApplication NumberEmail * Required Contact Person * Required First Last Title * RequiredPhone * RequiredIncorporated * RequiredYesNoExemptIncentive Payment Preference * RequiredCheckBill CreditPay ContractorPlease Assign Payment to Contractor * RequiredCustomer SignatureAdditional InformationSection B: CONTRACTOR INFORMATIONContact Person * Required First Last Contact Title * RequiredContractor Name * RequiredContact Person SignatureMailing Address * Required Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email * Required Phone * RequiredAdditional InfoIncorporated * RequiredYesNoExemptSection C: DOCUMENT APPROVALSPRE-INSTALLATION INSPECTIONUtility SignatureDate - must be mm/dd/yyyy format PRE-APPROVAL OFFERTechnical Review - Utility SignatureDate - must be mm/dd/yyyy format Utility SignatureDate - must be mm/dd/yyyy format Amount of Incentive OfferOffer Valid Through - must be mm/dd/yyyy format By signing and dating below, customer accepts this Incentive offer and agrees to the Utility Terms and Conditions available from your Utility. Pursuant to a Commission order, customers also agree that the utility alone may capture all kW and kWh savings and any ISO-NE capacity payments resulting from this energy efficiency project. This agreement is contingent upon continued approval and authorization by the Commission to recover said amounts from the System Benefits Charge. The Incentive, in conjunction with all other sources of funding, cannot exceed the total project cost.Customer Signature * RequiredDate - must be mm/dd/yyyy format Post-Installation InspectionOfficial NHEC Use OnlyUtility SignatureDate - must be mm/dd/yyyy format Customer SignatureDate - must be mm/dd/yyyy format Incremental Project Cost ($)Amount of Incentive ($)Management ApprovalDate - must be mm/dd/yyyy format New Equipment & Construction Custom Incentive Worksheet - Project DescriptionFor approved and qualified projects not covered by Prescriptive IncentivesEnergy Efficiency Measure * Requiredex: Replacing two Air Compressors/receiver with new compressorsBase Case or Code Compliant Equipment * Requiredex: two Modulating 50 hp Air Compressors, 400 gallon receiverTotal Base Case or Code Cost * RequiredProposed Energy Efficient Equipment/Measures * Requiredex: two new 75 hp VFD Air Compressors, 1060 gallon receiverTotal Energy Efficiency Cost * RequiredProject Type * RequiredElectric OnlyGas OnlyDual FuelsAdditional InfoIncremental Project Cost and IncentivesEnergy Efficiency Project Cost * RequiredBase Case Project Cost * RequiredEnergy Efficiency Incremental Project Cost * Required*Incentive shall not exceed the lesser of 75% of the incremental project cost or buy down to 1 year pay-back. Incentive is calculated by Utility Representative. Customer Caps may apply.Estimated Incentive*to be filled out by an NHEC representativeIncentive * 75%to be filled out by an NHEC representativeIncentive* 1 Yrto be filled out by an NHEC representativeBenefit Costto be filled out by an NHEC representativeEnergy and Other SavingsAnnual kWh SavingsSummer Peak kWh6AM-10PM, M-FSummer Off-Peak kWh10PM-6AM, M-F, plus weekends and holidaysWinter Peak kWh6AM-10PM, M-FWinter Off-Peak kWh10PM-6AM, M-F, plus weekends and holidaysTotal Annual kWh Savings * RequiredkW Demand SavingsSummer MinSummer AvgSummer MaxWinter MinWinter AvgWinter MaxkW Savings Dec5-7PM, M-F, less holidayskW Savings Jan5-7PM, M-F, less holidayskW Savings Jun1-5 PM, M-F, less holidayskW Savings Jul1-5 PM, M-F, less holidayskW Savings Aug1-5 PM, M-F, less holidaysAnnual Gas Fuel SavingsSeasonal Heatingmeasured in ThermsDomestic Hot Watermeasured in ThermsOthermeasured in ThermsOther ExplanationAnnual "Other" SavingsOilin gallonsLPin gallonsKerosenein gallonsWoodin cordsPelletsin tonsWaterin gallonsSewerin gallonsOther Annual $annual $Other One-Time $one-time $Additional Project Description/Other InformationPlease attach vendor proposals and supporting energy saving calculations * Required File uploadAccepted file types: pdf, jpg, doc, docx.Allowed file extensions - pdf jpg doc docx. 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