American Insulation

Andres
Ph: 209-216-1950 Fax: 209-216-1954
Energy savings
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Property Owner Waiver Assistance Program •

FOR ENERGY SAVINGS ASSISTANCE PROGRAM USE ONLY: OWNERSHIP DOCUMENTATION

Name of Tenant residing in the home-Owner/Renter lplease circle onel Phone Number

Name of Legal Property OwnerlLandlord or Property Manager (the "Landlord") Phone Number

Address of property and/or dwelling unit to be weatherized (the MPremises"J Unit Numbers

City ZIP

TENANT'S ACKNOWLEDGEMENT RELEASE AND WAIVER

The undersigned, rTenant agrees to the following terms of this acknowledgement. release and waiver (the "AgreemenC):
M
)

1. I am the above-named and legal tenant of the Premises described above, and I am 7. I understand that the Installer must determine whether my attic ventilation
authorized to sign this acknowledgement, reLease and waiver on behalf of myself and meets the requirements of the current local building code and inform me if
all other persons residing at the address listed above (collectively, the -Occupants-I. additional venting should be installed. I understand and agree that PG&E cannot.
I am also the utility customer who is, or may be, eligible to receive the Work for the and does not. determine if my ventilation is adequate and, therefore, disclaims
purposes of this Agreement. any responsibility or warranty. implied or explicit. for any problems arising from
2. I acknowledge that I have reviewed and understood each and every term of the release and the adequacy 01 my attic ventilation,
waiver contained in this Agreement. and I agree to be bound by its terms and conditions. 8. I further understand that PG&E or lnstallerlsl may need to inspect my
3. I understand that the Work will be performed at the Premises listed above and at NO COST combustion appliances for safety. PG&E or its contractor{sl may contact a
TO ME, and that no lien will be placed against me or the Premises relating to such work. Gas Service Representative to adjust or disconnect an appliance.
I further understand that I am not obligated in any way to participate in any other utility 9. I understand that, in order to qualify for a refrigerator replacement as a
programs that may have a cost association because I am participating in the Work, permissible weatherization measure, the refrigerator must be (a) manufactured
Renter's initials: _ _ Owner's initiaLs: _ _ before 1999 and operational; IbJ the primary refrigerator (e.g., located in the
kitchen!; and (cJ drawing power through a grounded three-prong outlet.
4. In consideration for the performance and receipt of the Work at the Premises, which has
been paid for by PG&E, at no cost to me, 1 hereby expressly waive and release on behalf 10. As the Tenant, I hereby give my permission for the Work !including. but not
of myself and aU Occupants claiming by. through or under me, any and all claims against limited to, a refrigerator replacement!.
PG&E and its officers and employees for any damage. injury, loss or liability caused by the Renter'sinitials: _ _ yes_no_ Owner'sinitials: _ _ yes_no_
ENERGY SAVINGS ASSISTANCE PROGRAM, even if PG&E is actively or passively negligent, 11. As the Tenant. I understand and agree that in the event that the Property
arising from or relating to this Work; provided. however. that nothing in this Agreement Owner owns a refrigerator that is replaced. the new refrigerator will remain
shaH constitute a waiver of any claims that I may have against any other participants in
the property of the Landlord, If the outlet into which the refrigerator plugs is
the ENERGY SAVINGS ASSISTANCE PROGRAM, such as the contractor who performs
not grounded, it is my responsibility to ground the outlet.
the Work or any other related measures (the "Installer"]'
Renter's initials: _ _ Owner's initiills: _ _
5, I hereby authorize the ENERGY SAVINGS ASSISTANCE PROGRAM Inslaller access
to the above~Usted Premises as necessary to perform the Work, subject to available
12.1 authorize PG&E to share the information on this form. as well as Information
on the weatherization and other related energy efficiency measures installed
funding and the Instalter's taking reasonable steps to perform the Work 50 as to minimize
in the Unitlsl at the address listed above, with municipal agencies, state or
significant disruption to my enjoyment of the Premises, unless required by law or other
federaL agencies. other utilities or their agents to facilitate enrollment in their
causes beyond the InstaUer"s reasonable control.
assistance programs and to improve the coordination and services under
6. I hereby authorize PG&E. lhe Installer and ENERGY SAVINGS ASSISTANCE PROGRAM assistance programs provided by PG&E, other utilities, municipal agencies.
Staff reasonable access to the Premises for the purpose of inspecting the Work of the and state and federal agencies.
ENERGY SAVINGS ASSISTANCE PROGRAM Inslallers. Renter's initials: _ _ Owner's initials: _ _

Signature of Tenant Date Signature of Legal Owner/Landlord or Property Manager Date

PROPERTY OWNER ACKNOWLEDGEMENT, RELEASE AND WAIVER I CERTIFY THAT I am the Legal Property Owner, Landlord or Property Manager of
the owner of this property, and that all given statements are true and correct to the
best of my knowLedge.
The undersigned, _--,-_.,,----,----:-:-_.,--:-;-_ _--;-,.,---;-;----:-;-;--,---,-...,--_...,------;_ _
Legal Property Owner. Landlord or Property Manager of the Unit{sl listed above, hereby
grants permission to the above-listed Tenant to arrange for, or otherwise cause, the
performance of the Work in the Un ids! !including, but not limited to, a refrigerator Name of Legal OwnerlLandlord or Property Manager (Please Print)
replacement if my refrigerator qualifiesl yes_ no_.1 acknowledge that I have read, and
agree to be bound by, each of the terms and conditions set forth above. I further agree that
if the weatherization and minor repairs are furnished to the UnitlsJ that I will not increase
Address City
the rental rates or evict the Tenant for participating in the ENERGY SAVINGS ASSISTANCE
PROGRAM, I understand that the Work will be performed at no cost to me or my tenants,
and that no liens will be placed against the Unit(s) or any other part of my property.
State ZIP Phone Number

Ownership Documentation Viewed (Signature of Energy Specialistl Signature of Legal Property Owner/Landlord or Property Manager Dote

"PG&E- ~ers to PaCific Gas and Electnc Company. a subsidiary of PG&E Corporation. Cl2014 PaCIfic Gas and Electnc Company. All nghts reserved. The Energy 5.'MngsAsSlstance Program from PaCifIC Gas and ElectriC
Company IS available to selected. Income-qualified customers. These offerings are fundpd by Cabforma uhtlty customers and admmlstered by PG& E under the auspices 01 the Call/orma Public UtiLities CommlsSKln
English June 2014 CSP-0614·]854
Distribution: White Copy-Customer· YeUowCopy-ContrKtor