Fillable Home Weatherization and Residential ENERGY STAR Rebate Application (City of Azusa)

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Home Weatherization and Residential ENERGY STAR Rebate Application (City of Azusa)

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The Home Weatherization and Residential ENERGY STAR Rebate Application (City of Azusa) form is 4 pages long and contains:

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  • 5 check-boxes
  • 165 other fields

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U.S.A. forms for City of Azusa

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Page 1
Home Weatherization and Residential ENERGY STAR®
Rebate Application
Name _______________________ Azusa Light & Water Account # _______________
Service Address __________________________________________, Azusa, CA 91702
Mailing Address ______________________________________ (if different from above)
Phone # ___________________ Email Address _______________________________
Tax Payer ID/SS Number (required for rebates $600 or more): _____________________
Please Check Each to Complete:
Must have original or copy of sales receipt or paid invoice showing date of purchase within
the last 6 months, model number, actual purchase price (excluding taxes and recycling fees)
and quantity
Original piece of packaging with the ENERGY STAR® Logo or product Efficiency Rating
Under no circumstances shall the rebate exceed the cost of the product
All applicable section(s) on rebate form are completed
Signature and date on last page of this application
ENERGY STAR® EQUIPMENT AND APPLIANCES
List of qualified products and incentives are subject to change without prior notice.
Rebate is limited to the cost of the device when applicable.
Products
Maximum
Total Incentive
Quantity Cost
Purchase
Date
Rebate
Appliances/Devices
1
Clothes Washer, Dishwasher,
Refrigerator, and Freezer
(Limit one each/year)
$75/each
2
Heat Pump or Energy Star
Electric Clothes Dryer
$200/each
3
Induction Range/Cooktop
(Limit one/5 years)
Existing electric
Gas to electric
$250/each
$500/each
4
Air Cleaner and Humidifier
(Limit 2 per residence/year)
$50/each
Page 2
5
Web-based Thermostat
(Limit 2 per residence/5 years)
$50/each
6
Electric Vehicle Charger
(Limit one per residence/year)
$150/each
7
Pool Pump
Multiple/Variable Speed High
Efficiency Replacement
Spa pumps not eligible
$200/each
8
Electric Water Heater
(Limit 1 per residence/10 years
Storage (30 Gallon or Greater)
Instantaneous and Point of Use
Types
Energy Factor (EF) 0.93 or greater
$500/each
Heat Pump Storage Type
(30 Gallon or Greater)
Energy Factor (EF) 2.0 or greater
$500/each
9
Room Air Conditioner
Limit 2/year
$50/each
10
Ceiling Fan
Limit 5/year
$50/each
11
Water Cooler
5 Gallon Tank Minimum
Limit one/year
$50/each
LED Lighting
Solar powered lights and new construction are not eligible for this rebate.
(Rebate limit $10 each, up to $200/year)
12
LED Lighting Fixtures, Lamps,
Holiday Lights, Decorative Light
Strings (Including Light& Sensor
Combo Units) and Lighting
Occupancy Sensors & Exterior
Photocells
Electronics
(Limit one each per household/year)
13
Audio/Video
Home Theater-in-a-Box Systems,
Soundbars, MP3 Speaker Docks, Audio
Amplifiers, AV Receivers, Shelf Systems,
Blu-Ray Disc Players, DVD Players, Set-
Top Boxes and Cable Boxes
$20/each
14
Computers/Equipment
Computers, Tablets/Pads, Slates,
Notebooks/Laptops, LED Monitors, Data
Storage, Small Network Equipment (such as
Cable & DSL Modems)
$50/each
15 LED TV (42” or larger) $100/each
16
Communications Equipment
Voice-Over-Int
ernet Protocol (VoIP)
Phones, Optical Network Devices, Cable &
DSL Integrated Access Devices, Routers,
Switches, Access Points
$20/each
17
Uninterruptible Power Supply
(UPS)
$50/each
18
Other Electronics Equipment &
Smart Power Strips*
*Other Energy Star Rated electronics not
otherwise listed will be considered on a case
by case basis at ALW’s discretion)
$20/each
Page 3
Central Air Conditioning/Heat Pumps
New construction and mobile homes are not eligible for this rebate.
Product
Maximum
Total Incentive
Quantity Cost
Purchase
Date
Rebate
1
Packaged Systems
SEER 15 – 15.9
$100/ton
SEER 16 – 16.9
$110/ton
SEER 17 – 17.9
$120/ton
SEER 18+
$130/ton
Heat Pump Electric Space Heating
SEER 15+
Existing electric
Gas to electric
$750/each
$2,000/each
2
Mini-Split Ductless Systems
SEER 15 – 15.9
$125/ton
SEER 16 – 16.9
$170/ton
SEER 17 – 19.9
$220/ton
SEER 20+ and evaporative cooled
$350/ton
Heat Pump Electric Space Heating
SEER 16+
Existing electric
Gas to electric
$750/each
$2,000/each
Home Weatherization Products
Product
Maximum
Total Incentive
Quantity Cost
Purchase
Date
Rebate
1
Insulation -Attic/Wall/Radiant
Barrier, Films and Shades, Cool
Roof
New construction does not qualify.
Attic must be at least R-30 and R-19 for
limited space. Walls must be at least R-13.
$0.25/Square Foot
(SF)
2
Attic Ventilation Fans
(Limit 2 per residence/year)
New construction does not qualify.
Electric (Har
dwired) Up to $50/each
Solar Powered and Whole House Up to $150/each
3
Duct Testing and/or Sealing
Up to $50 annual
maximum
4
Blower Door Air Leak Test
Up to $100 annual
maximum
5
Door/Window Weather Strip
and Caulking
Up to $50 annual
maximum
6
Air Conditioner Tune-Up
and Recharge
Up to $25/Ton
annual maximum
7
Skylights/Light Tubes
ENERGY STAR® rated
(Limit 1 unit per room)
Must have a solar heat gain coefficient
(SHGC) of 0.60 or less and U-factor of 0.40
or less. Provide National Fenestration Rating
Council (NFRC) label off each unit or the
Manufacturer’s order confirmation sheet.
Up to $175/each
8
Window Replacements
ENERGY STAR® rated
New construction does not qualify
$1.00/Square Foot
(SF)
Page 4
Participant Agreement
The energy-efficient product(s) marked above have been installed at the Azusa location indicated. I
have attached a copy of the itemized proof of purchase sales or paid invoice other required
documentation. I understand that falsifying information may lead to my disqualification from this
incentive program and that Azusa Light & Water will take appropriate actions to recover the rebate
amount. Funding is limited and this program is subject to change or cancellation without prior notice. I
have read and agree to these terms and to verification of installation by an Azusa Light & Water
representative, or contracted third party, as necessary.
I further understand that all residential rebates will be applied as a credit to my electric utility
account on or after the next billing cycle. Commercial/Industrial/Institutional rebates will be
issued as a check.
Customer Signature ______________________________ Date ____________________
If you have any questions, contact us at 626-812-5225 or rebates@azusaca.gov. Go to our website at
www.azusalw.com for up-to-date rebate requirements and qualifications.
Mail or Hand Deliver Application to:
Azusa Light & Water
729 N. Azusa Avenue, Azusa, CA 91702
Attention: Residential Rebates
Note: City of Azusa permits may be required for work done in the City of Azusa. Permits may be
obtained from the Building Division. You may contact them at 626-812-5234 for related questions.
(Modified: 10-14-2020)
REBATE GRAND TOTAL: ________________
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Home Weatherization and Residential ENERGY STAR Rebate Application (City of Azusa)

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Completed 15 January 2021

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