Milestone Completion Form

 Commercial‐Scale Ground‐Source Heat Pump Program Milestone Completion Form To be completed and signed by the System Owner and with the assistance of the Primary Designer and/or Primary Installer and submitted by the date indicated on the Award Letter to [email protected] with “GSHP Project Milestone – Project Site Name” in the subject. Award # (found in Award Letter): ____ System Owner Name: System Owner Organization: Primary Designer Name: Primary Designer Organization: Milestone Payment Amount: Date of Milestone Completion: Explanation of changes to Project Costs from those proposed in Application (if applicable): Project Cost Certification Please complete Table 1 below at the submission of each Milestone, which shows all Project costs incurred to date (i.e. costs for which the customer has been invoiced). This Project Cost Certification is subject to the Participant’s Agreement between MassCEC and the System Owner, as well as the Primary Designer and Primary Installer Agreement between MassCEC and the Primary Designer and Primary Installer. By signing below, the undersigned certify that Table 1 hereto sets forth a complete and accurate detailed summary of the costs and expenses incurred by the System Owner in connection with the completion of the Milestone. Table 1: Project Costs Incurred Project Element Design & Engineering Cost Design & Engineering Test Borehole Equipment: Heat Pump Loop Piping Other – Describe: Labor/Installation: Heat Pump Drilling/Excavation Loop Installation Other – Describe: Ineligible Project Costs: Internal Distribution Upgrades ‐ Equipment Internal Distribution Upgrades ‐ Labor Existing System Removal Miscellaneous: Describe Total Project Cost: System Owner Signature: _________________________________________________________ Date: ___________________ Primary Designer/Installer Signature: ________________________________________________ Date: Milestone #1: System Design and Equipment Purchase To be submitted upon completion of Milestone #1 Attachment Checklist: 1. Revised Application form, if applicable 2. AHRI rating certificates for newly selected units, if applicable 3. Primary Designer and Primary Installer Agreement, if not already submitted 4. Design and engineering plan and drawings
By signing below, I, the Primary Designer identified above, certify that for the design of the ground‐source heat pump project at the location identified above: 
The system has been designed in a manner that is in compliance with all federal, state, and local codes, regulations, and bylaws and meets all Program requirements; and 
The equipment selected meets all Program requirements.
Primary Designer Signature: ____________ Primary Designer Name: ____________ Date: ____________ By signing below, I, the System Owner identified above, certify that for the equipment for the ground‐source heat pump project at the location identified above: 
All equipment purchases have been completed, or a contract has been signed to purchase the equipment.
System Owner Signature: System Owner Name: Date: ____________ ____________ ____________ Milestone #2: Construction and Commissioning To be submitted upon completion of Milestone #2 Attachment Checklist: 1. Permitting authority signoff 2. Demonstration of start‐up (one of the following): a. Commissioning Report, or b. Manufacturer Start‐Up Sheet 3. Invoices detailing all Project costs incurred, if retrofit of existing GSHP system only 4. Electric Bill, if new construction For Direct Exchange systems only MassDEP Underwater Injection Control (UIC) no.: ____ By signing below, I, the Primary Installer identified above, certify that for the installation of the ground‐source heat pump project at the location identified above: 
The Project is in compliance with all federal, state, and local codes, regulations, and bylaws; 
All permits and signatures have been secured; 
All equipment has been installed in a manner that meets all Program requirements and in accordance with the design approved by MassCEC; 
All equipment has been inspected and tested according to manufacturer guidelines; and 
The equipment installed is the equipment identified in the Application, unless otherwise indicated above. Primary Installer Signature: ____________ Primary Installer Name: ____________ Date: ____________ By signing below, I, the System Owner identified above, certify that for the installation of the ground‐source heat pump project at the location identified above: 
The Project is in compliance with all federal, state, and local codes, regulations, and bylaws; 
All permits and signatures have been secured; 
All equipment has been installed in a manner that meets all Program requirements and in accordance with the design approved by MassCEC; 
All equipment has been inspected and tested according to manufacturer guidelines; and 
The equipment installed is the equipment identified in the Application, unless otherwise indicated above. System Owner Signature: System Owner Name: Date: ____________ ____________ ____________