Energy Conservation Assistance Program Application

Energy Conservation Assistance Program Application

Date of Application

Organization Information

Name of Organization*

Organization Address*

Example: 10 Main Street, Fairfax, Virginia, 22030

Organization Type if "Other"

Tax Identification Number (EIN Number)*

Magisterial / Supervisor District*

Select

Contact Information

Contact Name*

Contact Position within Organization*

Phone Number*

Phone

Email Address*

I am authorized to make purchases on behalf of my organization.*

Yes

Do you have a secondary contact to add to this application?*

Select

Secondary Contact Name

Secondary Contact Position within Organization

Secondary Contact Phone Number

Phone

Secondary Contact Email Address

I am authorized to make purchases on behalf of my organization.

Yes

Your reimbursement check will be mailed. Please check if the mailing address is different from the Organization Address and add the mailing address for the check below.

Mailing Address

Example: Contact Name, 10 Main Street, Fairfax, Virginia, 22030

Application Questions

Has your organization received an Energy Conservation Assistance Program reimbursement grant previously through the Northern Virginia Soil and Water Conservation District CAP-E?*

Select

Is the proposed project a recommendation from an energy audit?*

Select

Please include the energy audit as an attachment with the application as applicable. You will be asked to upload attachments at the end of the application.

Please select the project category for the current application. Select all that apply.*

Category 1 – Energy Audit

Category 2 – Energy Efficiency and Conservation Projects

Category 3 - Clean Energy/Renewable Energy

Category 4 – Resilience Projects

Please provide a brief description of the project and include a description of the site and/or problem the proposed project will address, how the project was identified, scope of project, and major equipment/supply quantities.*

Please provide information about the building or site where the project will be installed:

Site Address:*

Site Square Footage:*

Site Year Built:*

Year of any previous renovations:*

Type (N/A) if no previous renovations.

Site Property Owner:*

Estimated Project Start Date

Estimated Project End Date

What is the estimated annual cost savings?*

Type (N/A) if this project is an energy audit.

What is the estimated annual energy savings (kWh/year or kBtu/year)?*

Type (N/A/) if this project is an energy audit.

How were the reductions in energy use and costs determined?*

Type (N/A) if this project is an energy audit.

What is the total project budget (in dollars)?*

Please include materials and labor, and attach contractor bid(s) as applicable. 2-3 estimates are recommended.

Who will install the new equipment or perform the required services? Select all that apply.*

Contractor

Volunteer

Paid Community Members

The organization will maintain the installed project following industry standard practices for the expected life of the project/equipment/materials.*

Yes

Equity Consideration

The Energy Conservation Assistance Program provides a higher reimbursement for projects located in areas with a “High” or “Very High” Vulnerability Index or identified as “Disadvantaged” by the federal Justice 40 index. Staff will use the address for the project location and maps for the Vulnerability and Justice 40 indices to determine if the higher reimbursement amount applies to the application. Please refer to the Resources on the webpage for these mapping tools.

I have read and understand the equity consideration for the Energy Conservation Assistance Program.*

Attachments

A. Required. Letter(s) of support from the property owner, Board of Trustees, other governing body, or its designee, that it understands the Energy Conservation Assistance Program reimbursement cost-share program, is an allowable entity to make the changes to the building and/or property, supports the application and is willing to commit funds for implementation.

B. Required. Please provide evidence of your authority to bind the organization for the proposed project or services. For example, acceptable evidence may include a copy of the homeowners association's (HOA’s) governing documents, providing a link to a website or database, or the minutes of a recent meeting.

C. Required. Budget and/or at least two Contractor Bids or Quotes.

D. Required. Completed W-9 form.

E. Required for HVAC projects. Load calculation report. Preferred reports using Manual J for residential-sized units, Manual N for light commercial units. Load calculations in a spreadsheet will not be accepted. Contact the program for guidance if larger units are proposed at oeecinfo@fairfaxcounty.gov.

F. Optional. Photos of existing equipment to be replaced or existing site or project conditions to be remedied or addressed.

G. As applicable. Completed Energy Audit

Upload all attachments here.*

If you are having issues uploading attachments, please send an email to oeecinfo@fairfaxcounty.gov.

Drag and drop files here or

Send me a copy of my responses

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