5900-189 Modular Home Completion Report

OMB Control No. 2060-0586

ENERGY STAR^® Qualified Homes, Version 2.5

Modular Home Completion Report

Instructions

To qualify for ENERGY STAR, a home must meet the National Program Requirements and the measures listed in these checklists:

• Design Requirements Checklist (either Prescriptive Path or Performance Path)

• Thermal Enclosure System Checklist

• HVAC System Quality Installation Checklist

_{• HVAC System Quality Verification Checklist}

_{• Water Management System Checklist (or Indoor airPLUS Verification Checklist)}¹

Checklist items flagged for field verification are verified by a Rater.² Raters are expected to use their experience and discretion to verify that the overall intent of each inspection checklist item has been met (i.e., identifying major defects that undermine the intent of the checklist item versus identifying minor defects that the Rater may deem acceptable). The column titled “N/A,” which denotes items that are “not applicable,” should be used when the checklist item is not present in the home or conflicts with local requirements.

In the event that a Rater finds an item that is inconsistent with the intent of the inspection checklists, the home cannot earn the ENERGY STAR until the item is corrected. If correction of the item is not possible, the home cannot earn the ENERGY STAR.

The Rater is required to keep electronic or hard copies of the completed and signed checklists. The signature of the HVAC technician is required if any of the HVAC equipment specified on the HVAC System Quality Installation Checklist is installed in the home.

To receive the home label(s) and certificate, the Rater must send this Modular Home Completion Report,

a copy of all completed and signed Inspection Checklists and a check for $50 per home* (builder’s report processing fee for home certificate and site label) to:

Systems Building Research Alliance

1776 Broadway, Suite 2205

New York, NY 10019

Please allow up to 5 days for delivery. For 2-Day delivery, enclose an additional $20 S&H fee.

* If this is a plant certification home, the following processing fees apply (select one):

 $150 plant certification home ($100 for plant QA label + $50 builder’s fee)

- OR -

 $100 “temporarily installed” plant certification home³ (for plant QA label only)

Send labels to (check one):

 Certifier / Rater Primary Contact Contact:

 Field Inspector / Tester Company:

 Modular Plant Address:

 Modular Builder City:

 Homeowner State: Zip:

_{ Other (specify in space at right) Phone or Email:}

¹ A completed and signed Indoor airPLUS Verification Checklist may be completed by the Rater and submitted in lieu of the

Water Management System checklist. For more information, see the EPA website: www.epa.gov/indoorairplus.

² The term “Rater” refers to the person completing the third-party inspections required for qualification. This party may be a certified Home Energy Rater, Rating Field Inspector or BOP Inspector.

³ Temporarily installed homes must be re-inspected by a Rater when installed on the final home site and a new Completion

Report must be submitted along with the $50 report processing fee for the home certificate and site label.

_{Home Address: HOME ID:}

_{City: State: Zip:}

_{Homeowner Name: Phone:}

1. CONTACT INFORMATION

_{Certifier / Rater Primary Contact Field Inspector / Tester (if different from Primary Contact)}

Company Contact Name Company Contact Name

Address Address

City	State	Zip		City	State	Zip
Phone	Fax			Phone	Fax
Plant and QC Staff				Builder
Corporate Parent (if applicable)				Company	Contact Name
Plant Name	QC Contact Name			Address
Plant City	State	Zip		City	State	Zip
Phone	Fax			Phone	Fax

_{HVAC Contractor / Technician HVAC System Designer (if different from Cont. / Tech.)}

Company Contact Name Company Contact Name

Address Address

City State Zip City State Zip

Phone Fax Phone Fax

2. WAS THIS HOME TESTED?  Yes  No If No, skip to question 5.

3. HOUSE TIGHTNESS

a) Infiltration rate ( ≤ 6.0 in CZs 1, 2 | ≤ 5.0 in CZs 3, 4 | ≤ 4.0 in CZs 5, 6, 7 | ≤ 3.0 in CZ 8). Measured: ACH50 ....................

4. DUCT TIGHTNESS (fill in and check ONE)

a) Duct leakage to outdoors ( ≤ 6 CFM25 Performance Path; ≤ 4 CFM25 Prescriptive Path). Measured: CFM25 / 100 sq ft ...

_{*Homes with < 1,200 sq ft CFA: ≤ 5 CFM25 / 100 sq ft}

- OR -

b) All ducts and air handling equipment are located within the home’s air and thermal barriers and envelope leakage has been tested to be

≤ 3.0 ACH50 in CZs 1, 2 | ≤ 2.5 ACH50 in CZs 3, 4 | ≤ 2.0 ACH50 in CZs 5, 6, 7 | ≤ 1.5 ACH50 in CZ 8. .....................................................

5. QUALITY ASSURANCE (QA) LABEL (must check ONE to pass)

a) An SBRA quality assurance (QA) modular home label is affixed to home interior and signed and dated by a factory representative ...........

- OR -

b) This is one of the factory’s initial three certification homes. The plant QA label will be signed and affixed with the blue ENERGY STAR^®

Qualified New Home site label (see instructions) ................................................................................................................................................

6. CERTIFIER / RATER EVALUATION (check ONE)

a) PASSES: No discrepancies were identified......................................................................................................................................................... b) PASSES: Minor discrepancies were identified and repaired, and the home was re-inspected ........................................................................ c) FAILS: Discrepancies are described below .........................................................................................................................................................

Signature of Certifier / Rater: Date:

Modular Home Completion Report

_{PROBLEMS / DISCREPANCIES & REMEDIATION ACTIONS HOME ID:}

_{Item No. Discrepancy}

_Remediation

_{Item No. Discrepancy}

_Remediation

_{Item No. Discrepancy}

_Remediation

_{Item No. Discrepancy}

_Remediation

_{Item No. Discrepancy}

R

EPA Form 5900-189

The government estimates the average time needed to fill out this form is 0.25 hours and welcomes suggestions for reducing this effort. Send comments (referencing OMB Control Number) to the Director, Collection Strategies Division, U.S. EPA (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460.

emediation

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www.research-alliance.org

Rev. 9/2011