Deemed Energy Savings Method
Energy Savings Scheme
April 2016
© Independent Pricing and Regulatory Tribunal of New South Wales 2016
This work is copyright. The Copyright Act 1968 permits fair dealing for study, research, news reporting, criticism and review. Selected passages, tables or diagrams may be reproduced for such purposes provided acknowledgement of the source is included.
Enquiries regarding this document should be directed to a staff member:
ESS Enquiries(02)92908452 or
Independent Pricing and Regulatory Tribunal of New South Wales
PO Box K35, Haymarket Post Shop, NSW 1240
Level 15,2-24 Rawson Place, Sydney NSW 2000
T (02)92908400 F (02)92902061
Document Control
Version number / Change description / Date publishedV1.0 / Initial release– following gazettal of ESS Rule Amendment No.2 / 3 September 2014
V2.0 / Nomination form separated from Method Guide / 8 January 2015
V3.0 / Updated to reflect amendments to the ESS Rule / April 2016
Nomination Form Template – Installation of High Efficiency Appliances for BusinessV3.0IPART / 1
Contents
1Introduction
2Nomination Form Template - Corporation
3Nomination Form Template – Individual
Nomination Form Template – Installation of High Efficiency Appliances for BusinessV3.0IPART / 11Introduction
This document sets out the approved template nomination form for the Installation of High Efficiency Appliances for Business Method under the Energy Savings Scheme. Details regarding the use of this template can be found in the associated Method Guide for the Installation of High Efficiency Appliances for Business Method available on the website.[1]
The nomination form generated from this nomination form template is to be used to:
nominate a person as an Energy Saver under the ESS Rule (where the original Energy Saver is nominating another person to be the Energy Saver),[2] and
provide certain information as evidence to the Scheme Administrator that the End-User Equipment has been or will be installed in accordance with ESS requirements.
The nomination form generated from Section 2 is to be used where the originalEnergy Saver is a corporation and an authorised signatory is signing the nomination form on behalf of that Energy Saver. A corporation here includes a company, a statutory corporation, an incorporated association and a trustee corporation.
The nomination form generated from Section 3 is to be used where the originalEnergy Saver is an individual (including a sole trader) and is signing the nomination form as the original Energy Saver.
1.1How to use the Nomination Form Template
To use the nomination form template, you will need to:
cut and paste the wording from this document into your own document
format as appropriate
do notchange the words or add additional items to the declaration (for instance your own terms and conditions)
request the original Energy Saver to complete Part A including:
–the sections of the form in square brackets
–sign and date the form, and
as the Accredited Certificate Provider, complete Part B of the form including:
–the sections of the form in square brackets
–sign and date the form.
The suggested wording may not be appropriate in all circumstances, so you may need to modify it. If you wish to use wording other than the recommended wording, you will need to submit your wording for approval by the Scheme Administrator via email at .
Nomination Form Template – Installation of High Efficiency Appliances for BusinessV3.0IPART / 12Nomination Form Template –Corporation
Energy Saver nomination(Part A)
To be completed by the originalEnergy Saver (ie Purchaser) making the nomination
Original Energy Saver detailsCorporation name / [Click and type here] /
ABN / [Click and type here] /
Implementation address / [Click and type here] /
Postal address / [Click and type here] /
Phone number / [Click and type here] /
Past activities
Have you signed a nomination form for this activity in the past? (If yes, please provide a reason for the amended nomination form.)
[Click and type here]
Is the site a residential building[3] or small business building[4]?
[Click and type here]
(If yes, the energy savings from a high efficiency air-conditioner cannot form part of this nomination)
Activities to be implemented at the site
Install a High Efficiency Refrigerated Display Cabinet / ☐
Install a High Efficiency Liquid Chilling Package / ☐
Install a High Efficiency Close Control Air-Conditioner / ☐
Install a High Efficiency Air-Conditioner / ☐
Install a Brushless DC Motor to power a Refrigeration Fan / ☐
Install a Brushless DC Motor to power a Ventilation Fan / ☐
Install a new High Efficiency Motor / ☐
Declaration by original Energy Saver:
I, on behalf of[original Energy Saver], nominate [Accredited Certificate Provider] as the Energy Saver in respect of the activity or activities identified above. This nomination is effective to entitle [Accredited Certificate Provider] to create and own all Energy Savings in respect of each of the above activities at the implementation address listed above once activities are completed and Energy Savings commence.
I hereby declare that:
I am an authorised signatory of the[original Energy Saver].
I have received the contact details of the Accredited Certificate Provider named in Part B.
[original Energy Saver]is the person who has purchased or leased, or will be purchasing or leasing, the relevant goods (such as equipment) or services at the implementation address as part of the activity/activities identified above.
[original Energy Saver] has not purchased or leased, or will not be purchasing or leasing, the goods or services for the purpose of reselling the equipment, unless the resale will be an inclusion in a contract for the sale of land, or in a strata scheme, the sale of a lot.
Except as set out above, I have not previously made another nomination in respect of the above activities at this address under the Energy Savings Scheme (ESS).
To the best of my knowledge, [original Energy Saver]has not, except as set out above, previously made another nomination in respect of this activity at this address under the ESS.
[original Energy Saver]agrees to provide information regarding the above activities and provide reasonable access to the site to a representative of the ESS or a member of the ESS Audit Services Panel, should it be required.The information provided is complete and accurate and I am aware that there are penalties for providing false or misleading information in this form.
Note:Section 158 of the Electricity Supply Act 1995 imposes a maximum penalty of $11,000 and/or six (6) months imprisonment for knowingly providing false or misleading information to the Scheme Administrator.
Signed by or on behalf of the originalEnergy Saver
Signature
Name of authorised signatory / [Click and type here] /
Position / [Click and type here] /
Date / [Click and type here] /
Accredited Certificate Provider(Part B)
To be completed by the Accredited Certificate Provider receiving the nomination from the originalEnergy Saver (ie Purchaser) named in Part A
ACP detailsName / [Click and type here] /
Company name / [Click and type here] /
ABN/ACN / [Click and type here] /
Postal address / [Click and type here] /
Phone number / [Click and type here] /
Declaration by authorised signatory
I hereby declare that:
I am an authorised signatory of the Accredited Certificate Provider named above.
The activity/activities to be conducted at the implementation address identified in Part A of this form will not result in a reduction of service levels (including safety levels).
The information contained in this form is correct and accurate.
I am aware that there are penalties for providing false or misleading information in this form.
Where the activity includes installation of a high efficiency air-conditioner, the implementation site is not a Residential Building[5] or Small Business Building.[6]
Note:Section 158 of the Electricity Supply Act 1995 imposes a maximum penalty of $11,000 and/or six (6) months imprisonment for knowingly providing false or misleading information to the Scheme Administrator.
Section 138 of the Electricity Supply Act 1995 imposes a maximum penalty of $220,000 for failure to comply with a condition of accreditation and may additionally result in the suspension or cancellation of the Accredited Certificate Provider’s accreditation under clause 95 of the Electricity Supply (General) Regulation 2001.
Signed by or on behalf of the Accredited Certificate Provider
Signature
Name of authorised signatory / [Click and type here] /
Position / [Click and type here] /
Date / [Click and type here] /
Nomination Form Template – Installation of High Efficiency Appliances for BusinessV3.0IPART / 1
3Nomination Form Template – Individual
Energy Saver nomination(Part A)
To be completed by the originalEnergy Saver (ie Purchaser) making the nomination
Original Energy Saver detailsName / [Click and type here] /
ABN (where applicable) / [Click and type here] /
Implementation address / [Click and type here] /
Postal address / [Click and type here] /
Phone number / [Click and type here] /
Past activities
Have you signed a nomination form for this activity in the past? (If yes, please provide a reason for the amended nomination form.)
[Click and type here]
Is the site a residential building[7] or small business building[8]?
[Click and type here]
(If yes, the energy savings from a high efficiency air-conditioner cannot form part of this nomination)
Activities to be implemented at the site
Install a High Efficiency Refrigerated Display Cabinet / ☐
Install a High Efficiency Liquid Chilling Package / ☐
Install a High Efficiency Close Control Air-Conditioner / ☐
Install a High Efficiency Air-Conditioner / ☐
Install a Brushless DC Motor to power a Refrigeration Fan / ☐
Install a Brushless DC Motor to power a Ventilation Fan / ☐
Install a new High Efficiency Motor
Declaration by original Energy Saver
I, [original Energy Saver], nominate [Accredited Certificate Provider] as the Energy Saver in respect of the activity or activities identified above. This nomination is effective to entitle [Accredited Certificate Provider] to create and own all Energy Savings in respect of each of the above activities at the implementation address listed above once activities are completed and Energy Savings commence.
I hereby declare that:
I have received the contact details of the Accredited Certificate Provider named in Part B.
I am the person who has purchased or leased, or will be purchasing or leasing, the relevant goods (such as equipment)or services at the implementation address as part of the activity/activities identified above.
I have not purchased or leased, or will not be purchasing or leasing, the goods or services for the purpose of reselling the equipment, unless the resale will be an inclusion in a contract for the sale of land, or in a strata scheme, the sale of a lot.
Except as set out above, I have not previously made another nomination in respect of the above activities at this address under the Energy Savings Scheme (ESS).
I agree to provide information regarding the above activities and provide reasonable access to the site to a representative of the ESS or a member of the ESS Audit Services Panel, should it be required.
The information provided is complete and accurate and I am aware that there are penalties for providing false or misleading information in this form.
Note:Section 158 of the Electricity Supply Act 1995 imposes a maximum penalty of $11,000 and/or six (6) months imprisonment for knowingly providing false or misleading information to the Scheme Administrator.
Signed by or on behalf of the originalEnergy Saver
Signature
Name of Signatory / [Click and type here] /
Position / [Click and type here] /
Date / [Click and type here] /
Accredited Certificate Provider(Part B)
To be completed by the Accredited Certificate Provider receiving the nomination from the original Energy Saver (ie Purchaser) named in Part A
ACP detailsName / [Click and type here] /
Company name / [Click and type here] /
ABN/ACN / [Click and type here] /
Postal address / [Click and type here] /
Phone number / [Click and type here] /
Declaration by authorised signatory
I hereby declare that:
I am an authorised signatory of the Accredited Certificate Provider named above.
The activity/activities to be conducted at the implementation address identified in Part A of this form will not result in a reduction of service levels (including safety levels).
The information contained in this form is correct and accurate.
I am aware that there are penalties for providing false or misleading information in this form.
Where the activity includes installation of a high efficiency air-conditioner, the implementation site is not a Residential Building[9] or Small Business Building.[10]
Note:Section 158 of the Electricity Supply Act 1995 imposes a maximum penalty of $11,000 and/or six (6) months imprisonment for knowingly providing false or misleading information to the Scheme Administrator.
Section 138 of the Electricity Supply Act 1995 imposes a maximum penalty of $220,000 for failure to comply with a condition of accreditation and may additionally result in the suspension or cancellation of the Accredited Certificate Provider’s accreditation under clause 95 of the Electricity Supply (General) Regulation 2001.
Signed by or on behalf of the Accredited Certificate Provider
Signature
Name of authorised signatory / [Click and type here] /
Position / [Click and type here] /
Date / [Click and type here] /
Nomination Form Template – Installation of High Efficiency Appliances for BusinessV3.0IPART / 1
[1]Refer
[2]See clause 5.2(b)(i) of the ESS Rule.
[3]“Residential Building” means a building classified by the BCA as a Class 1 or Class 2 building, and may include any Non-Habitable Building on the same site
[4]“Small Business Building” means a building comprising total floor space less than 200 square metres and classified by the BCA as a Class 6 building
[5]“Residential Building” means a building classified under the Building Code of Australia as a Class 1 or Class 2 building, and may include any Non-Habitable Building (such as a garage) on the same site
[6]“Small Business Building” means a building comprising total floor space less than 200 square metres and classified by the Building Code of Australia as a Class 6 building
[7]“Residential Building” means a building classified by the BCA as a Class 1 or Class 2 building, and may include any Non-Habitable Building on the same site
[8]“Small Business Building” means a building comprising total floor space less than 200 square metres and classified by the BCA as a Class 6 building
[9]“Residential Building” means a building classified under the Building Code of Australia as a Class 1 or Class 2 building, and may include any Non-Habitable Building (such as a garage) on the same site
[10]“Small Business Building” means a building comprising total floor space less than 200 square metres and classified by the Building Code of Australia as a Class 6 building