Form 17650 Heat Pump Plan Work Completion Form

Energy Right Program

17650

Energy Right Program

OMB: 3316-0019

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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]

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleEnergy right® Program
AuthorEMPLOYEE OF TVA
File Modified0000-00-00
File Created2021-01-27

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