17651 New Homes Plan Work Completion Form

energy right® Program New Homes 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.

Inspection (open) Date:

     

(mm/dd/yyyy)

4.

Rating File Name:

     

or

     

(*.blg, other)

(Prescriptive Standard)

5.

Efficiency Rating Version:

     

or

     

Software Version (RR, other)

(Prescriptive Standard)

6.

Builder Name:

     

Builder is Homeowner

7.

Legal 911 Address of New Home:

     

     

Street Address

City, State, Zip Code

8.

Inspector Name:

     

9.

Total Conditioned Floor Area:

     

(square feet)

10.

Structure:

Single Family

Multi-Family

11.

Installed Heat Pump:

ASHP-Package

ASHP-Split

Advanced-Geo

Advanced-Triple Function

Dual Fuel Heat Pump

Multi-Speed Compressor Heat Pump

Other

12.

Number of New Homes Completed at this Address with Efficiency Rating of:

energy right (93 to 86)

     

energy right Platinum ( 85)

     

energy right Platinum Certified ( 85)

     

For Platinum Certified homes only:

HERS Provider

     

HERS Certification Number

     

13.

HERS Rating Index:

     

14.

Total Cooling Capacity:

     

(tons)

15.

Number of Advanced Water Heaters Installed:

     

16.

Total Water Heating Capacity:

     

(gallons)

17.

Average Cooling Efficiency:

     

SEER

18.

Number of New Homes Inspected at this Address:

     

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

1.

Subdivison or Customer Name:

     

2.

Account Number:

     

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.

QCN:

Yes

No

QCN Contractor:

     

7.

Building Floor Levels:

     

8.

Water Heater Brand:

     

9.

Date Passed Local Standards:

     

(mm/dd/yyyy)

10.

Incentive Paid:

$

     

Retained MVP:

$

     

11.

Rating Certified by:

     

12.

Natural Gas Available?

Yes

No

13.

Contractor Paid?

Yes

No

14.

Comments:

     

Builder’s Signature

Inspector’s Signature

Date Completed

Signatures may be collected on Builder Affidavit

TVA 17651 [08-23-2011]