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<br /> SNOHOMISH COUNTY' 11
<br /> Commercial&Industrial Energy Efficiency Services
<br /> Pli DINCENTIVE&TECHNICAL ASSISTANCE PROGRAM
<br /> PUBLIC UTILITY DISTRICT NO.1 .WORK AUTHORIZATION
<br /> Note: Due to limited conservation funds,this form must be signed and returned before August 15,2011
<br /> to be valid. The work identified within this document must be completed and pass P.U.D.inspection on or before
<br /> November 15,2011 in order to be paid by the Agreement Expiration Date:
<br /> December 15,2011
<br /> Facility Name Business/Building Owner Official Name(for payment)
<br /> Tax ID Number Authorization Date
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<br /> 07/13/11
<br /> Owners Mailing Address(for payment) PUD Staff
<br /> Facility Address « t, tr n 9 y.. r�A a s r O Ply $ 'qe,a4 3k aN Fee. n e t Kern Satre
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<br /> Ci y State � �z� "' � State Zip Project Number
<br /> State Zip City
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<br /> v 4j * 0 19/250 ''P, T.ures Ith 20 n 'di; $19,476.00 T $1,025.05 $2,879.41 14,397 kWh $1,014
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<br /> Totals qq12L476 00 r � Yes',�+ 8�944' 1 i•',s.. /° k4x ' .. ..
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<br /> Incentive as a%of Project Cost► 'k a„1 >° �xx I k ((_1 y• ,.
<br /> Savings as a%of Facility Total Annual Electrical Use
<br /> Measure&Verification(M&V) p Q L
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<br /> 1,the undersigned,understand the energy cost savings shown are estimates. These estimates are based on standard engineering calculations. I further
<br /> understand that I will not be eligible to receive payment until measures funded by the program have been installed an passed inspection by Public Utility
<br /> District No.1 of Snohomish County(the"PUD"). The actual-Incentive shall not exceed 70%of the authorized project cost for existing facilities. For new
<br /> construction project,the incentive shall not exceed 50%of authorized material cost or full Incremental cost. I understand that any changes In project
<br /> scope requires prior authorization before proceeding.
<br /> I agree to indemnify and hold harmless the PUD and each and all of its agents or employees from and against any and all losses,liabilities,damages,
<br /> costs,expenses(including reasonable attorneys'fees and expense),claims,judgments arising out of or in connection with participant in this program. I
<br /> understand it is the sole responsibility of the building owner or agent to obtain building andlor electrical permits,inspections and approvals
<br /> whenever they are required by taw and to dispose of existing hazardous waste appropriately(see Lighting Waste Disposal Form).
<br /> I hereby certify that the information contained on this form is,to the best of my knowledge,true and correct. I understand and will comply with the time
<br /> constrained listed.
<br /> Date ID I D 52 1I D
<br /> Authorized Signature
<br /> Sr 9-1 ll
<br /> Print Name
<br /> Tile PUD Approval
<br /> Version tb-020111
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<br /> 61
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