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2. Smart Irrigation Controller Retrofit Program Application
4. PROGRAM RULES AND REQUIREMENTS

   • Applicant must be Town of Firestone water utilities customer.

   • Program is not available for new construction.

   • Only single-family residential properties can apply.

   • Only one application can be submitted per property.

   • At least one year of prior water usage at the property is required to qualify.

   • Applicant must have and maintain Wi-Fi service at the property at all times. The smart irrigation controller will continuously be connected Wi-Fi and to operate the ET weather information connection. This network connection will need to be established during set installation.

   • Smart irrigation controller retrofit must be installed and applicant must schedule an onsite inspection of controller retrofit with the Town of Firestone within 30-day of receipt.

   • All blanks below must be completed for application to be processed.

   • Provide proof of US citizenship or legal status in the United Sates by providing a photocopy of one of listed forms of identification on the Affidavit of Lawful Presence sheet. Complete the Affidavit of Lawful Presence form.

   • Please allow up to 4 to 6 weeks for application to be processed and to be notified that this application meets all program rules and requirements.

   • Irrigation controllers will not be available until April 2017, due to weather conditions being acceptable for installation.

6. APPLICANT INFORMATION
8. Town of Firestone Water Account Number: (Located on your water bill)*
9. Property Owners Name:*
11. Property Address: (Address where controller is being installed)*
12. Mailing Address: (if different from the property address)
14. City:*
15. State:*
16. Zip:*
18. Telephone Number:*
19. Email Address:*
21. PROPERTY/INSTALLATION SITE INFORMATION
23. Does the property currently have Wi-Fi?

    1. Yes
    2. No
25. Does the property currently have a programmable irrigation system?

    1. Yes
    2. No
27. If yes, is the irrigation system installed in the front and back yard?

    1. Both front and back
    2. Front only
    3. Back only
29. If no, do you have plans to install a programmable irrigation system in the front and back yard?

    1. Yes
    2. No
31. If yes, where?

    1. Both front and back
    2. Front only
    3. Back only
32. If yes, when?
34. Number of total zones in existing or planned irrigation system:
35. How many days per week is the property irrigated normally?
37. Length of time irrigated per zone each time:
38. If no programmable irrigation system is currently installed, what is the length of time the yard is irrigated each time?
40. Current programmable irrigation controller Brand:
41. Current programmable irrigation controller Model No:
43. Date of installation of current programmable irrigation controller:
45. TERMS AND CONDITIONS
47. In order to receive the Smart Irrigation Controller Retrofit, the property owner understands and agrees to the following conditions:

    1. I understand that the controller retrofit program is subject to availability of funding and is provided on first-come, first-served basis.

    2. I understand and I meet all specified program rules and requirements from the first page and I understand that the Town of Firestone Water Utilities Department can deny any application that does not meet program rules and requirements (which can change without notification).

    3. I understand I will be responsible for picking up the controller retrofit from the Town of Firestone at 9950 Park Ave., Firestone, CO 80504 once I am notified that my application has been approved.

    4. I understand the installation of controller and material are my responsibility.

    5. I understand and agree that all work performed will comply with applicable state and local laws, ordinances, and regulations.

    6. I understand and agree that the Town of Firestone Water Utilities Department staff will inspect my property to confirm that the controller was installed, done so properly, and is operating for its intended purpose. If the inspection, whenever performed, shows that the device is not installed or being used as represented in this application, I agree to reimburse the Town the full price of $207.48 for a four-station controller or $232.96 for an eight-station controller, which ever I received. I agree the reimbursement would be a charge placed on my water bill for the full amount of the controller I received.

    7. I understand that property shall be available for future inspection and monitoring (up to five years) by Town of Firestone Water Utilities Department staff. Town of Firestone Water Utilities Department staff, while on site for inspections may take photos of the project. Property addresses participating in the controller retrofit program will be available to the public. Customer names will not be made public or associated with the property address.

    8. I understand and agree that installation of irrigation equipment or landscape materials may not result in lower water bills.

    9. The Town of Firestone is not responsible for the cost of installing or maintaining the Wi-Fi service used to operate and maintain the smart irrigation controller.

    10. If this application is approved by Town of Firestone Water Utilities Department, and the work proceeds, I agree to defend, indemnify, and hold harmless Town of Firestone, its agents and employees against any and all loss, liability, expense, claims, suits and damages, including attorney’s fees, arising out of or resulting from the installation of irrigation equipment and landscape equipment.

    11. I have read, understand, and agree to the terms and conditions of the program for which I am applying.

49. CHECK HERE*

    1. I agree my electronic submission of this form constitutes my signature affirming the above information is true and correct.
51. Property Owner Signature*
52. Date*
    Date
54. COMPLIANCE AND IDENTIFICATION REQUIREMENT
56. Dear Town of Firestone Water Customers,
    
    We would like to inform you of a step in the application process with which you must comply before receiving your controller retrofit.
    
    On July 31, 2006, Governor Bill Owens signed into law House Bill 06S-1023, which restricts who may receive public benefits in the State of Colorado. Under the new law, any individual person older than 18 years of age must prove lawful presence in the United States in order to receive non-emergency public benefits, such as the rebate for which you have applied. The new law went into effect August 1, 2006.
    
    In order to prove lawful presence in the United States, you must produce one of the following forms of identification:
    • a valid driver’s license from one of the following states that the Colorado Department of Revenue has deemed eligible: Colorado, Alabama, Arizona, Arkansas, California, Connecticut, Delaware, District of Columbia, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Minnesota, Mississippi, Missouri, Montana, Nevada, New Hampshire, New Jersey, New York, North Dakota, Ohio, Oklahoma, Pennsylvania, Rhode Island, South Carolina, South Dakota, Virginia, West Virginia, or Wyoming;
    • a valid Colorado identification card;
    • a United States military card;
    • a United States military dependent’s identification card;
    • a United States Coast Guard Merchant Mariner card;
    • a Native American tribal document;
    • a Naturalization or citizenship certificate;
    • a Court-issued adoption order;
    • an I-94 immigration form with refugee or asylum status;
    • an unexpired resident alien card, permanent resident card, temporary resident card or employment authorization card.
    
    You may upload a copy of your identification (in one of the forms listed above) to the link below, or mail or drop off a photocopy of your identification to the Town of Firestone at 151 Grant Ave/P.O. Box 100 Firestone, CO 80520. We assure you that this information will remain highly confidential. You may remove/darken all sensitive information such as social security numbers from the copy of your identification that you submit to the Town of Firestone.
    
    In addition, completion of the affidavit below is also required.
    
    We regret any inconvenience these requirements may cause you.
    
    Sincerely, Town of Firestone
58. Upload copy of identification*
60. AFFIDAVIT OF LAWFUL PRESENCE
62. I,*
64. swear or affirm under penalty or perjury under the laws of the State of Colorado that (check one)

    1. I am a United States citizen, or
    2. I am not a United States citizen, but I am a Permanent Resident of the United States, or
    3. I am not a United States citizen, but I am lawfully present in the United States pursuant to Federal law.
66. I understand that this sworn statement is required by law because I have applied for a public benefit. I understand that state law requires me to provide proof that I am lawfully present in the United States prior to receipt of this public benefit. I further acknowledge that making a false, fictitious, or fraudulent statement or representation in this sworn affidavit is punishable under the criminal laws of Colorado as perjury in the second degree under Colorado Revised Statute 18-8-503 and it shall constitute a separate criminal offense each time a public benefit is fraudulently received.
68. CHECK HERE*

    1. I agree my electronic submission of this form constitutes my signature affirming the above information is true and correct.
70. Signature*
71. Date*
    Date
75. OFFICE USE ONLY
77. Veritification by:
78. Date
80. Application:

    1. Approved

    1. Denied
82. Additional Notes
Leave This Blank:


84. 1. Receive an email copy of this form.
85. Email address

    This field is not part of the form submission.

86. Submit Submit and Print

* indicates a required field