5900-189 Completion Report for Energy Star Modular Home

Completion Report for ENERGY STAR Modular Home

1. CONTACT INFORMATION

a) Rater primary contact b) Rater field tester (if different from primary contact)

Company Name		Company Name
Address		Address
City State Zip		City State Zip
Telephone Email		Telephone Email

c) Factory d) Builder

Corporate Parent		Company Name
Plant name		Address
Plant City Plant State Zip	Zip	City State Zip
		Telephone Fax

e) Homeowner f) Home location

Name		Address
Telephone		City State Zip

Was this home tested?  Yes  No If No, skip to question 4. Conditioned space sq. ft.:

2. House tightness (must fill in and check to pass)

   1. ACH50. Measured: ______________ (must be ≤ 7.0 in CZ 1-2 | ≤ 6.0 in CZ 3-4 | ≤ 5.0 in CZ 5-7 | ≤ 4.0 in CZ 8) 

3. DUCT TIGHTNESS (must fill in and check ONE to pass)

   1. Duct leakage to outside at 25 pascals. Measured: ______________ (must be ≤ 4 cfm to outdoors / 100 sq. ft.) 

   2. All ducts and air handling equipment are in conditioned space and envelope leakage tests
      at ≤ 3 ACH 50 or ≤ 0.25 cfm 50 per sq. ft. of building envelope. 

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

   1. An SBRA quality assurance (QA) ENERGY STAR Modular Home Label is affixed to the home interior and signed
      and dated by a factory representative 

   2. This home is one of the factory’s initial three certification homes (QA label will be affixed with site label – see below) 

5. RATER EVALUATION (check one)

   1. PASSES: No discrepancies were identified. 

   2. FAILS: Discrepancies are described on the following sheet. 

Signature of Rater: Date:

Complete all applicable items and send with a completed copy of the Inspection Checklist for ENERGY STAR Qualified Modular Homes and, if home passes, a check for $40 (or $140 if this is one of the initial three factory certification homes) to: Systems Building Research Alliance, 2109 Broadway, Suite 200, New York, NY 10023.

Description of problems/discrepancies and remediation actions

Item number: _____	Discrepancy
	Remediation
Item number: _____	Discrepancy
	Remediation
Item number: _____	Discrepancy
	Remediation
Item number: _____	Discrepancy
	Remediation