Category 1 Application

Section 5
Guidelines for Certified Inverter-Based Generating Facilities,
10kw and Less
Interconnection Application

* - Indicates that a field is required

1. Interconnection Customer

* Company or Last Name, First Name of Customer:

* Customer (Last Name, First Name):

* Contact Person (Last Name, First Name):

* Street Address:

* City:

* State:

* Zip:

Mailing Address (if different):

City:

State:

Zip:

* Customer's CL&P Account Number (on the customers CL&P bill):

* Meter Number (on the customers CL&P bill):

* E-mail Address:

* Phone Number:

* Fax Number:

* Responsible party's name and contact information in case of emergency:
(provide day, evening and weekend contact information)

* Is this a new service?:

Yes
No

* Is this Interconnection Request for?:

A retail customer interconnecting a new Certified Inverter-Based Generating Facility that will produce electric energy to be consumed only on the retail customer site
A generating facility where 100% of the excess output will be sold to its host utility
An Interconnection Customer interconnecting a new Certified Inverter-Based Generating Facility that plans to participate in the wholesale markets

2. Point of Contact (if different from Interconnection Customer i.e. Developer)

Company:

Representative(First Name, Last Name):

Title:

Street Address:

City:

State:

Zip:

Mailing Address (if different):

City:

State:

Zip:

E-mail Address:

Telephone number:

Fax number:

*3. Requested In Service Date
(If you do not use the date picker, please enter the date in mm/dd/yyyy format.)

4. Generating Facility / Inverter Information

*a. Manufacturer:
*b. Model No.:
Version No.:
Serial No.:
*c. Generating Facility Phase Type:
Single Phase Three Phase

*d. Nameplate AC Rating:	KW



*e. Generating Facility/Inverter AC output voltage (volts):
f. Rated Current (amps):
*g. Prime Mover:
Photovoltaic Reciprocating Engine Fuel Cell Turbine Other

* Energy Source:
Solar Wind Hydro Diesel Natural Gas Fuel Oil Other

*h. UL1741 Listed:

Yes
No

i. Single line diagram of interconnection and site plan.

Upload

(Use the browse button to select the attachment, then click the upload button to add it to the form. Please try to limit to 4 attachments.

5. Liability Insurance Send us your certificate of liability insurance
Carrier:
Limits:
Agent Name:

6. Other Comments, Specifications and Exceptions:

The Inverter Process is available only for inverter-based Generating Facilities no larger than 10kW that meet the codes, standards, and certification requirements to UL 1741 as outlined in the Guidelines.

Interconnection Customer Signature

I hereby certify that, to the best of my knowledge, the information provided in this application is true. I agree and accept all terms and conditions for Interconnection and agree to abide by the "Guidelines for Certified Inverter-Based Generating Facility, 10kW and less" to interconnect a Certified Inverter-Based Generating Facility and return the Certification of Completion when the Certified Inverter-Based Generating Facility has been installed.

Submitted: 09/02/2010 11:45 AM