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<br /> 11
<br /> SNOHomisH COUNTY Commercial&Industrial Energy Efficiency Services
<br /> P!1 1) INCENTIVE&TECHNICAL ASSISTANCE PROGRAM
<br /> puCvc UTILIiY D157RICT 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: December 15,2011
<br /> Facility Name
<br /> Bus--.iness/Building OwnerOfiaa Nanle(for payment). .,.. Tax ID Number .., ...
<br /> Authorization Date te
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<br /> 4 .. sW/ ,a1 1°a-447.44,141.0.14%., . a � .. s a o p- --� • ' „t,. +`a07/13/11
<br /> Facility Address Owners Mailing Address(for payment) q PUD Staff
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<br /> Project Number
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<br /> Totals '14t8 Vi t'' ::, 2R1 :� '-r.. ,
<br /> incentNe as a%of Project Cost► • [ ° - . „ �,
<br /> Savings as a%of Facility Total Annual Electrical Use
<br /> Measure&Verification(M&V)
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<br /> I,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.
<br /> understandit is the sole responsibility of the building owner or agent to obtain building and/or electrical permits,inspections and approvals
<br /> whenever they are required by law 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 /> Ippl 12
<br /> Authorized Signature Date 51- /
<br /> lt
<br /> Print Name Title PUD Approval
<br /> Version lb-020111.
<br /> 62
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