This Application is considered complete when it provides all applicable and correct information required below. Additional information or clarification to evaluate the Application may be requested by the City.

Processing Fee

A non-refundable processing fee of $25 must accompany this Application.

Customer

Name: _______________________________________________________________________________

Contact Person:________________________________________________________________________   

Address:  _____________________________________________________________________________

City: ____________________________________ State: _______________________ Zip: ____________

Telephone (Day):__________________________ (Evening): ____________________________________

Fax: _____________________________________E-Mail Address: _______________________________

 

Contact (if different from Customer)

Name: _______________________________________________________________________________

Contact Person:________________________________________________________________________   

Address:  _____________________________________________________________________________

City: ____________________________________ State: _______________________ Zip: ____________

Telephone (Day):__________________________ (Evening): ____________________________________

Fax: _____________________________________E-Mail Address: _______________________________

 

Owner of the facility: ___________________________________________________________________

 

Generating Facility Information

Location (if different from above): _________________________________________________________

Electric Service Company: ________________________________________________________________

Account Number:_______________________________________________________________________

Inverter Manufacturer: __________________________________________________________________

Model: _______________________________________________________________________________

Nameplate Rating:        (kW)_____________________________(kVA)____________________________

(AC Volts)       Single Phase _____________ Three Phase  _____________

System Design Capacity: __________________(kW) __________________(kVA)

 

Prime Mover:	Photovoltaic o	Reciprocating Engine o	Fuel Cell o
	Turbine o	Other___________
Energy Source:	Solar o	Natural Gas o	Hydro o
	Diesel o	Wind o	Fuel Oil o

Other (describe)__________________________________________

Is the equipment UL1741 Listed?       Yes ________________ No ________________

If Yes, attach manufacturer's cut-sheet showing UL1741 listing

 

Estimated Installation Date: ________________ Estimated In-Service Date: ________________

List components of the Small Generating Facility equipment package that are currently certified:

Equipment Type                       Certifying Entity

1.  ________________             ________________________________

2.  ________________             ________________________________

3.  ________________             ________________________________

4. ________________              ________________________________

5. ________________              ________________________________

Customer Signature

I hereby certify that, to the best of my knowledge, the information provided in this Application is true. I agree to abide by the terms and conditions of the City's Interconnection Standard and will return the Certificate of Completion when the Generating Facility has been installed.

Signed:_________________________________________________________________________

Title:___________________________________________  Date:___________________________

 

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Contingent Approval to Interconnect the Generating Facility

Interconnection of the Generating Facility is approved contingent upon the terms and conditions of the City's Interconnection Standard and upon return of the Certificate of Completion.

City Signature: __________________________________________________________________           

Title:___________________________________________  Date:___________________________

Application ID number: ________________ 

City waives inspection/witness test? Yes ______ No ______