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Multifamily Energy Savings Program HVAC EQUIPMENT WORKSHEET

THIS APPLICATION IS FOR EXISTING BUILDINGS ONLY.

This application expires December 31, 2013. Return signed, completed application with accompanying worksheet(s) and itemized invoice postmarked within 60 calendar days of project installation, but no later than December 31, 2013, unless an earlier date is specified by Focus on Energy. Focus on Energy incentives are subject to change. Please visit focusonenergy.com/multifamily to ensure you are using the most current form. This worksheet must be accompanied by a completed Prescriptive Incentive Application. Questions: Call 866.486.0832 Property Name: Installation Address: VARIABLE SPEED GAS FURNACE n Furnaces must be 90% Annual Fuel Utilization Efficient (AFUE) and have a sealed-combustion unit. Air handlers are not eligible. n Furnaces must have a multi-stage burner and a variable-speed Electronically Commutated Motor (ECM) for the blower (Permanent Split Capacitor or multi-speed motors are not eligible). n Chimney liners must be installed where a high-efficiency gas furnace replaces an atmospherically drafted furnace and only a water heater remains vented through the chimney. The interior opening left by the removed furnace must be closed with a metal cap and sealed with caulk or mortar. n 90% AFUE Furnace with ECM, Natural Gas, Propane or Oil-Fired $125 Incentive: n Furnace must have an AFUE of 90% or greater. n Must be customer of a participating electric utility. Natural gas, propane and oil-fired furnaces are eligible. Electric furnaces are not eligible. n 95% AFUE Furnace with ECM, Natural Gas Only $275 Incentive: n Furnace must have an AFUE of 95% or greater. n Must be customer of a participating electric utility and a participating natural gas utility. Customer must use natural gas for space heating. New Equipment 90% AFUE Variable Speed ECM and multiple stages of heating Requirements and Required Information Manufacturer: __________________________________________ Model Number: _________________________________________ Serial Number: _________________________________________ Manufacturer: __________________________________________ Model Number: _________________________________________ Serial Number: _________________________________________ $275 $125 Incentive Quantity Total

95% AFUE Variable Speed ECM and multiple stages of heating

SPLIT SYSTEM AIR CONDITIONER n The condenser model and serial number, evaporator model and serial number, and AHRI (Air Conditioning, Heating and Refrigeration Institute) reference number are required for installations. n System efficiency is based solely on the evaporator and condensor coils; the SEER may not be increased by factoring in the efficiency of a variable speed forced air  heating system fan, except where a two-stage air conditioner is installed. n All efficiency ratings will be verified using the AHRI database (ahridirectory.org). Note: Electric chillers are eligible for custom incentives only. n Refrigerant line diameters must meet manufacturers specifications. n Mini-split/ductless systems and air-source heat pumps that meet these efficiencies also qualify. New Equipment 14 SEER < 65 MBh (5.42 tons) AHRI Ref#: ___________________ 15 SEER < 65 MBh (5.42 tons) AHRI Ref#: ___________________ 16 SEER or greater < 65 MBh (5.42 tons) AHRI Ref#: ___________________ Requirements and Required Information Condenser Model Number: _________________________________ Condenser Serial Number: __________________________________ Size (tons; 1 ton = 12 MBh):_________________________________ Evaporator Model Number: _________________________________ Evaporator Serial Number: __________________________________ Existing Furnace Model Number required for two-stage A/C: ______________________________________________________ Replacing Existing A/C? q Yes Was Existing Operable? q Yes
q No q No

Incentive

Quantity

Total

$100

$150

$200

APPLICATION SUBMITTAL: R  eturn signed, completed form, worksheets and ITEMIZED invoice(s) to: Mail: Focus on Energy MESP, 12075 Corporate Parkway, Ste. 100, Mequon, WI 53092 E-mail: Applications and invoices may also be scanned and e-mailed to MESPapps@focusonenergy.com Fax: 262.240.0825 Questions: Call 866.486.0832

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Multifamily Energy Savings Program HVAC EQUIPMENT WORKSHEET

THIS APPLICATION IS FOR EXISTING BUILDINGS ONLY.

This application expires December 31, 2013. Return signed, completed application with accompanying worksheet(s) and itemized invoice postmarked within 60 calendar days of project installation, but no later than December 31, 2013, unless an earlier date is specified by Focus on Energy. Focus on Energy incentives are subject to change. Please visit focusonenergy.com/multifamily to ensure you are using the most current form. This worksheet must be accompanied by a completed Prescriptive Incentive Application. Questions: Call 866.486.0832 PACKAGED TERMINAL HEAT PUMP (PTHP) n Must meet both heating and cooling specifications. n Must replace a Packaged Terminal Air Conditioner (PTAC). Replacement of existing PTHP does NOT qualify. n All efficiency ratings will be verified using the AHRI database (ahridirectory.org). Equipment serial numbers are required. n Please attach a spreadsheet with unit location and serial number. This information is often found on warranty documentation and/or on the equipment nameplate. New Equipment PTHP Requirements and Required Information PTHP, 12.3 EER, 3.2 COP Incentive $100
n Equipment must be AHRI certified to standard 1060 and bear the AHRI  certification symbol for AHRI air-to-air energy recovery ventilation equipment certification program based on AHRI 1060. The website listing AHRI certified air-to-air recovery ventilators is ahridirectory.org. n Systems with ASHRAE or other independent testing may be eligible for custom incentives, pre-approval is required. Please contact Focus on Energy at 866.486.0832 for additional details.

Quantity

Total

ENERGY RECOVERY VENTILATOR (ERV) n Units replacing existing ERVs do not qualify. n Supply airflow is the rated leaving supply airflow (SCFM) as defined in AHRI standard 1060. n Please provide efficiency of the buildings cooling and heating systems. This information will not affect the ERV incentive. n Area served by ERVs must be air conditioned during the periods of June through August, 1:00 p.m. to 4:00 p.m. and heated during the winter. Replacement of existing ERV and use of ERV where required by state code does NOT qualify. New Equipment

Requirements and Required Information Manufacturer:_________________________________ Model Number: ____________________________________ Heat Exchanger Net Total Efficiency:

Incentive

Total

Must be AHRI certified AHRI Ref# (if applicable): ___________________________

Summer: _______________________________________ Winter: ___________________________________________ Rated SCFM: _______________________________________ Cooling System EER or kW/ton:___________________________ Heating System Efficiency %: _______ (or COP if heat pump): _______ Replacing Existing Energy Recovery Ventilator? q Yes q No $0.75/SCFM

DOMESTIC HOT WATER PLANT n This measure is for the replacement of an ENTIRE Domestic Hot Water (DHW) plant. Partial plant replacements may qualify for custom incentives, call 866.486.0832 for more information. n Water heaters must be stand-alone condensing units with a thermal efficency of 90% or an indirect storage tank connected to a boiler with an AFUE of 90%. n Indirect water heating systems input capacity eligible for incentive is only the capacity of the boiler supplying the indirect tank(s) not the entire boiler plant capacity. Only enter boiler information for boiler controlling indirect tank(s) below. n All leased water heaters must transfer ownership to the building owner upon the end of lease term. New Equipment Requirements and Required Information Manufacturer: ____________________ below Model Number: ___________________ Manufacturer: ____________________ Serial Number (s):__________________ Model Number: ___________________ Input Capacity: ____________________ Input Capacity: ___________________
For indirect tanks enter boiler information

Incentive

Total

DHW PLANT Number of Existing Water Heaters ______ Number of New Water Heaters______

$1.00/ MBh up to $1,500

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Multifamily Energy Savings Program HVAC EQUIPMENT WORKSHEET

THIS APPLICATION IS FOR EXISTING BUILDINGS ONLY.

This application expires December 31, 2013. Return signed, completed application with accompanying worksheet(s) and itemized invoice postmarked within 60 calendar days of project installation, but no later than December 31, 2013, unless an earlier date is specified by Focus on Energy. Focus on Energy incentives are subject to change. Please visit focusonenergy.com/multifamily to ensure you are using the most current form. This worksheet must be accompanied by a completed Prescriptive Incentive Application. Questions: Call 866.486.0832 INDIVIDUAL DOMESTIC WATER HEATERS n An eligible water heater must be an individual unit serving one residential unit. n Incentives for electric tank-type water heaters available only if natural gas is unavailable at the street through a participating utility. New Equipment Natural Gas Power Vented Tank-type 0.67 EF Natural Gas Power Vented Tankless-type .82 EF Natural Gas Condensing 90% Thermal Efficiency Natural Gas Indirect with Modulating Boiler 90% AFUE Electric Tank-Type 0.93 EF Requirements and Required Information Manufacturer: _________________________ Model Number: ________________________ Serial Number: ________________________ Manufacturer: _________________________ Model Number: ________________________ Serial Number: ________________________ Manufacturer: _________________________ Model Number: ________________________ Serial Number: ________________________ Manufacturer: _________________________ Model Number: ________________________ Serial Number: ________________________ Manufacturer: _________________________ Model Number: ________________________ Serial Number: ________________________ Incentive $50 Quantity Total

$100

$150

$200

$50

q By checking this box, I certify that I do not have access to natural gas where this electric water heater was installed.

Itemized Invoice Attached? q Yes

Date Installation Was Completed:

TOTAL Incentive REQUESTED

(all line items pages 1-2):

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