Form 17650 Heat Pump Plan Work Completion Form

energy right® Program Heat Pump Plan Work Completion Form

OMB No. 3316-0019 Expires: MM/DD/YYYY

1.

Power Distributor:

     

2.

Work ID Number:

     

(Work ID Number is assigned by energy right Information System)

3.

Unit Installed Date:

     

(mm/dd/yyyy)

4.

Number of Dwellings:

     

5.

Legal 911 Address of Dwelling or Business:

     

     

Street Address

City, State, Zip Code

6.

Structure Type: Single Family Multi-Family Business

7.

Type System Replaced: Electric Resistance Fossil-Fuel Heat Pump New Load

Other

     

8.

Type of Heat Pump Installed: Advanced Refrigerants Direct Exchange HP Dual Fuel HP Earth Coupled HP Free Delivery HP Ground Water Source HP Packaged Terminal HP Self Contained HP

Standard Air Source HP Triple Function HP Variable or Multi Speed Window HP

Other

     

9.

Number of Dwellings or Businesses with:

Split System Heat Pump, < 13 SEER:

     

Package System Heat Pump, < 13 SEER:

     

Split System Heat Pump, 13 to 13.99 SEER:

     

Package System Heat Pump, 13 to 13.99 SEER:

     

Split System Heat Pump,  14 SEER:

     

Package System Heat Pump,  14 SEER:

     

Split System Heat Pump, Advanced Units:

     

Package System Heat Pump, Advanced Units:

     

Note: Where a Dwelling or Business has more than one (heat pump) unit assigned to the load of a Dwelling or Business, the SEER rating is determined as either the efficiency of the primary system or a weighted-average efficiency of the units installed in the Dwelling or Business.

10.

Total Cooling Capacity Installed:

     

(tons)

11.

Number of Dwellings or Businesses Inspected:

     

12.

QCN Contractor:

     

13.

Inspector Name:

     

For Distributor Records (Complete the following where required by distributor):

1.

Customer Name:

     

2.

Account (or Meter) Number:

     

3.

Total Heating Capacity Installed:

     

kbtu

4.

Heat Pump Brand 1:

     

Heat Pump Brand 2:

     

5.

Average Heating Efficiency:

     

HSPF

or

     

COP

6.

Quality Validation Contractor:

Yes

No

7.

Water Heater Type:

     

8.

Security Filing Date:

     

(mm/dd/yyyy)

9.

Other Measures:

     

10.

Date Passed TVA Standards:

     

(mm/dd/yyyy)

11.

Date Passed Local Standards:

     

(mm/dd/yyyy)

12.

Incentive Paid:

$

     

Retained MVP:

$

     

13.

Natural Gas Available?

Yes

No

14.

Contractor Paid?

Yes

No

15.

Comments:

     

	Customer’s Signature		Inspector’s Signature		Date Completed

Signatures may be collected on Contractor - Homeowner Affidavit

TVA 17650 [08-23-2011]