Annex5
APPLICATIONFORM
CALL for projects FROm .....
IMPROVINGTHEENERGYEFFICIENCY IN publicly owned sites
No / date / month / yearFilled in by NTEF
Section 1 Applicant
1.1 / PROJECT TITLE / ......Site type / Kindergarten
Creche
School
- small school (up to 100 pupils)
- medium school (from 100 to 500 pupils)
- big school (more than 500 pupils)
Culturalcommunitycenter, heater, gallery or another cultural institution
Medical facility
Another type of sole trader company with 100% state or municipal participation
Sport hall
University dormitory
University building
Administrative building
Bulgarian Academy of Sciences (BAS) Institute
School dormitory
Street lighting
Other, what type
1.2 / SUBMITTER OF THE FORM
1.2.1 / Applicant / (Organization)
1.2.2 / Legal representative / (name)
1.2.3 / Organization type / Municipal administration
District organization
University
School
State institution
Regional unit of a state institution
BAS Institute
Company
Others, please list
1.2.4 / UIC (BULSTAT) number
1.2.5 / VAT number
1.2.6 / Official address
1.2.7 / Correspondence address
1.2.8 / Phone number
1.2.9 / Additional phone number
1.2.10 / Fax number
1.2.11 / E-mail address
1.2.12 / Web page
1.2.13 / Contact person (name and position)
1.2.14 / Phone, fax, e-mail address of the contact person)
1.3 /
APPLICANT’S CAPACITY
1.3.1 /Resources
(а) numberofthefulltimeandparttimeemployeesby categories(б) material-technical base – buildings and equipment
(в) employees, who will be involve in the project implementation (names and positions):
Name / Responsibilities under the project / Phone number for contact
1.
2.
3.
4.
...
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Section 2 Description of the project proposal
2.1
/PLACE OF PROJECT IMPLEMENTATION
DistrictMunicipality
Settlement / ......
Site / ......
2.2 / DESCRIPTIONOFTHEPROBLEM, WHICHISADDRESSED(shortpresentationofthestatusofthespecificproblem; backgroundinformationand hitherto existing actions for its solution, have funds from previous financing been used and how) maximum 500 symbols
2.3 / Projectobjectives
Describethegeneralandtheconcreteprojectobjectivesandinwhatwaytheresultsofitsimplementation willcontributetotheachievementofCIPobjectivesand particularly of the procedure, pursuant to which the project proposal has been submitted(maximum 1500 signs)
(clearlyspecifytheproposalobjectives, howtheywillbeachieved, theirimportancefortheprogram; DONOTinclude confidential information, formulas and their special requirements)
2.4 / TECHNICAL DESCRIPTION OF THE PROJECT–maximum1500symbols
(Descriptionandlistingorenergysavingmeasures, aswellastheirquantitativedimensions, whichleadtoproblemsolution and expected results; in case of investment projects: summary of proposed technology, presentation of possible alternative solutions; end products; implementation deadlines)
2.5 / ENERGY MANAGEMENT MEASURES(Energy consumption management and monitoring system) – maximum 1000symbols
(descriptionandlistingofimplemented/ envisioned for implementation energy management measures)
- Implemented energy management measures prior to project implementation (Short description and listing of the energy management measures)
- Envisioned with the present project energy management measures (Shortdescriptionandlistingoftheenergymanagementmeasures)
- Not implemented / energy management measures are not envisioned
2.6 / INFORMATION ON THE ENERGY CONSUMPTION PRIOR TO THE PROJECT IMPLEMENTATION
Table 1 / Electricity consumption for the previous calendar year in kWh:
Site:
Annual budget of the site for the period (BGN):
Year / Jan / Feb / March / April / May / June / July / Aug / Sep / Oct / Nov / Dec
Consumption in kWh
Paid amount
Table 2 / Paid heating bills for the previous calendar year (BGN):
Site:
Budget of the site for the period (BGN):
Year / Jan / Feb / March / April / May / June / July / Aug / Sep / Oct / Nov / Dec
Fuel type:
Paid amount:
Year / Jan. / Feb / March / April / May / June / July / Aug / Sep / Oct / Nov / Dec
Fuel type:
Paid amount:
2.7 / PROJECT ACTIVITIES AND BUDGET
Include the costs only for the eligible activities in compliance with the call.
Site:
No / Activity / Amount, VAT excluded / VAT / Total
(VAT included)
1 / Construction and installation works (CIW)
2 / Othereligibleactivities (constructionandauthor’ssupervisionand investment control – in total up to 3% of the CIW value)
Total(BGN):
2.8 / SOURCES OF PROJECT FUNDING (Only for the eligible activities!)TheNTEFgrantfortherelevantsites is stipulated in art. 2,par. 2 of the CIP Manual.
Sources of funding / Amount in BGN
(VAT is not included) / VAT / Amount with VAT / Percentage of the total project value
Grant from NTEF under CIP
Own funding
Other sources, what kind ....
Total project value / 100%
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2.9 / INVESTMENT COSTS FOR ESMTotal area in the building (m2)
Total volume of the building (m3)
Measures
(in compliance with the energy audit) / Quantity
(m2) / Unit price
(per m2) / Total
column.2х column 3 / VAT / Total, VAT included
1 / 2 / 3 / 4 / 5 / 6
TOTAL
2.10 / Expected energy savings and emission reduction – by sites and measures
(Calculation based on energy audit and projected electricity prices).
Table 2.10 is filled by the applicants, which are Clients within the meaning of PPA and RASPP.
Site: ......
Measures
(as in the energy audit) / Heat energy / Electrical energy / Saving - kWh / Emission reduction
Consumption of fuel / Consumption before the project - kWh / Consumption after the project - kWh / Emission factor / Consumption before the project kWh / Consumption after the project - kWh / Emission factor / Heat energy / Electri-cal energy / total
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2.11 / EXPECTED ENERGY CONSUMPTION CATEGORY FOLLOWING THE INTRODUCTION OF ESM2.12 / PROJECT IMPLEMENTATION DEADLINES
DeadlineforCIW implementation after the signing of contract with the contractors(number of months)
2.13 / Project readiness
Specify the applicable.
Project readiness / Yes / No / n/a / Notes
Availability of technical project under the Spatial Development Act (SDA)
Availability of project draft, under SDA
Energy audit
Certificate of current status of energy consumption, issued pursuant to Art. 17 of the Energy Efficiency Act (EEA) at the time of submission of the project proposal
Conformity assessment of the investment projectpursuant to Art. 142, Paragraph 5 of SDA for 1st and 2nd category building sites.
Decision of the approving authority’s council of experts in accordance with Article 142, paragraph 6 of the SDA, in the case of 3-rd, 4-th and 5-th category constructions;
Conformity Assessment of the investment project with the essential requirements under Art. 169, Paragraph 1, item 6, of the SDA, under Regulation 7 of 2004 on energy efficiency, heat and energy saving in buildings
Construction permit issued under Art. 148-156 of SDA (Please specify the date of issue in the "yes" box)
Price analysis per resource
Other – please, specify
Section 3 Project implementation indicators
3.1. / Measurable indicatorsSpecify aggregately for all sites
Indicators / Measuring unit
Number of persons directly benefiting from the improved infrastructure / number
Number of people benefiting indirectly from the improved infrastructure / number
Numberofjobscreatedfor the implementation of C&I works under the project / number
Numberofjobscreatedfor the project implementation as administration and project management / number
Energy savings due to buildings renovation (MWh/yearly average) / MWh
Savings of financial resources and energy (BGN, yearly average) / BGN/year
Improved infrastructure – sq. m. of built area / sq. m
Improved infrastructure / number
Reduction of greenhouse gases emissions (CO2 and equivalent) - t / yearly average / t/year
Amount of reduced emissions per unit (1000 BGN) of investment expenditure / t/ BGN 1000
3.2 / ADDITIONAL ENVIRONMENTAL BENEFITS – reductionofair, waterandsoilpollutionorbiodiversitypreservation, improvement of life and work quality (please describe - specify in quantities – not more than 1000 symbols):
3.3 / ENVISIONEDENERGYEFFICIENCY EDUCATIONAL MEASURES – list the measures, which will be implemented within the project framework and in the course of 5 years following the completion of the investment activities, providing a short description of the activity, the number of the participants and the projected value, which will be covered by you within the framework of the saved energy–not more than 1000 symbols):
Annexes to the application form:
-Site eligibility declaration (template – Annex2).
-Applicant eligibility declaration (template – Annex5.2).
-Copy of site title.
-Copy of Energy Audit+ certificate + summary;
-BoQ– arranged by energy saving measures(template – Annex5.1Excel и PDF).
-Letterofsupport/ consentfromtherelevantinstitution, whenthe candidate under the project is not this institution;
-Actual state certificate (for NGO) or excerpt from the Commercial register.
-State aid declaration (template – Annex5.4) (if applicable).
-Declaration for absence of duplication (template – Annex 5.3).
-CopyoftheAnnualFinancialReportsforthelastthreeyears (forcompaniesandNGOs).
-Documentforensuredfinancing (forthecompanies) and decision of the management body of the candidate for ensured co-financing.
______
*NTEF grant for the relevant sites is stipulated in art. 2, par. 2of CIP Operational Manual.
DECLARATION
We declare the correctness of the information in this application form and confirm that the project will be implemented as described here, and that the requested grant is only the minimum necessary amount for its implementation
We confirm that the organization will monitor the project to ensure its conformity with the document and with the relevant provisions, and shall apply appropriate measures for managerial and financial control.
WeconfirmthatthesubmittedapplicationformandthedocumentsintheNTEFportalfullycorrespondtothese same documents on a paper carrier.
We will immediately inform NTEF of the occurrence of any changes in the project, should they occur in the period between the application submission and the execution of the contract for funding.
Applicant’s name:Declarant’s name:
Title:
Date:
Signature and stamp:
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