Builders sample certificate, please complete
appropriate sections and can print any legible
size. Certificate must be post on site for final
inspection (please remove this note).
ENERGY EFFICIENCY CERTIFICATE N1101.9
(Certificate is required to be posted on electrical panel box, kitchen cabinet, attic
with insulation installers certificate or other approve location)
Builder, Permit Holder or Registered Design Professional
Print Name:
Signature:
Property Address:
Date:
Insulation Rating-List the value covering largest
area to all that apply (as applicable)
CEILING/ROOF
WALL
FLOOR
CLOSED CRAWL SPACE WALL
SLAB
BASEMENT WALL
FENESTRATION:
U-FACTOR
SOLAR HEAT GAIN COEFFICIENT (SHGC)
BUILDING AIR LEAKAGE
___ VISUALLY INSPECTED ACCORDING TO N1102.4.2.1 or
R-VALUE
RRRRR-N/A
RUU-
___ BLOWER DOOR TEST ACCORDING TO N1102.4.2.2
ACH50 [Target: 5.0] or CFM50/SFSA [Target: 3.0]
NAME AND ADDRESS OF TESTING COMPANY/INDIVIDUAL:
DATE:
PHONE: ( )
DUCTS:
DUCT INSULATION-UNCONDITIONED AREAS
DUCT INSULATION –SEMI-CONDITIONED AREAS
TOTAL DUCT LEAKAGE TEST RESULT
(SECTION N1103.2.2)
R-8
R-4
(CFM25 TOTAL/100SF) [TARGET: 6]
NAME AND ADDRESS OF DUCT TESTING COMPANY/INDIVIDUAL:
DATE:
PHONE: ( )
CERTIFICATE TO BE PERMANENTLY DISPLAYED