ENERGY CONSERVATION File No.

2190 REV. 6/10 APPLICATION

I am applying for a: ❏ LOAN (complete front and back) ❏ INCENTIVE (complete front only)
This is an application for (please check all that apply):
❏ Heat pump ❏ Windows ❏ Insulation ❏ Thermostat(s) ❏ Duct Sealing & Insulation
Address of Building to be Weatherized (Number & Street) City State Zip

Full Name of Applicant (must be owner of building) Social Security Number Birth date

Residence Address (Number & Street) City State Zip

APPLICANT

Mailing Address (if different from residence) (Number & Street) City State Zip

Home Phone Number Work Phone Number Cell Phone Number

( ) ( ) ( )
Contact Person (for home access if other than owner) Address Phone
( )
Employer Address How long?

1. Is the building heated by electricity? ❏ Yes ❏ No ❏ Don’t know

If so, what type?
❏ Electric Furnace ❏ Electric Baseboard ❏ Ceiling Cable ❏ Other (specify)
BUILDING INFORMATION

❏ Portable Electric Heat ❏ Electric Wall Units ❏ Electric Heat Pump

2. Do you have other heating equipment (used or unused) in the building? ❏ Yes ❏ No ❏ Don’t know
If so, specify:
❏ Oil Furnace ❏ Gas Furnace ❏ Wood Furnace ❏ Other (specify)
❏ Oil Space Heaters ❏ Gas Space Heaters ❏ Wood Stove / Insert

3. Does the building consist of more than one living unit (apartment, duplex, etc.)? ❏ Yes ❏ No ❏ Don’t know
If so, how many units are there in the building?
If so, how many stories are there in the building?

4. Is the home a mobile or manufactured home? ❏ Yes ❏ No ❏ Don’t know

How did you hear about our WEATHERIZATION program? (Please check all that apply.)
o Ad (TV, print, etc.) o PUD Bill Insert o PUD Brochure o Contractor or Retailer o Friend or Family o Email o PUD Web site
o “Current” Magazine o PUD Employee o Fair or Event o Community Power! o Energy Hotline o Letter o News story

THE FOLLOWING INFORMATION IS REQUIRED IN ORDER TO PROCESS THIS APPLICATION:

1. All sections of this application are complete.
2. An original signed bid on a PUD Uniform Bid sheet from a PUD Registered Installer. (Heat pump bids are required after
PUD inspection.)
3. A completed PUD Conservation Participation Agreement.
4. If applying for a condominium residence, please include an approval letter from your homeowners’ association.
5. Please sign at the bottom of this page.
6. If applying for a loan, please also complete the reverse side of this application.
IMPORTANT: PUD AUTHORIZATION IS REQUIRED BEFORE ANY WORK IS STARTED OR SUPPLIES PURCHASED.

✖
Signature of Owner or Authorized Representative Date
Please send completed paperwork to:
ATTN: Residential Services, Snohomish County PUD, PO Box 1107, Everett, WA 98206-1107
 THE FOLLOWING INFORMATION IS REQUIRED ONLY FOR LOAN APPLICANTS
NOTE: HOMES on leased or rented land are not eligible

1. A copy of your ownership document (e.g., Deed of Trust, Statutory Warranty Deed, Warranty Deed, Title, etc.)

2. A COMPLETE legal description of the property.

3. If you are signing for an owner, provide a copy of a notarized and recorded Power of Attorney.

Questions?
Energy Hotline: 425-783-1700
(Monday through Friday, 8 am to 5 pm, toll-free in Western Washington at 1-877-783-1000, extension 1700)

Name of Applicant (must be owner of building; list additional owners below) Social Security Number Birth Date

Residence Address (Number & Street) City State Zip

APPLICANT

Mailing Address (if different from residence) (Number & Street) City State Zip

Home Phone Number Work Phone Number Cell Phone Number

( ) ( ) ( )
Employer Address How long?

Names of Additional Owners (MUST INCLUDE BIRTH DATE & SOCIAL SEC. #) Birth Date Social Security Number
OTHER OWNERS

1. Are you an owner of the building to be weatherized? ❏ Yes ❏ No

LOAN INFORMATION

2. Do you own or lease/rent the land that the building to be weatherized ❏ Own ❏ Lease/Rent
is situated on?

3. Ownership is established by: ❏ Statutory Warranty Deed ❏ Deed of Trust ❏ Other

4. Are the property taxes current? ❏ Yes ❏ No

5. Is the home occupied by the owner? ❏ Yes ❏ No

IMPORTANT: PUD AUTHORIZATION IS REQUIRED BEFORE ANY WORK IS STARTED OR SUPPLIES PURCHASED.

✖
Signature of Owner or Authorized Representative Date