OMB Control No. 2060 - 0586



# ENERGY STAR® 

# Qualified Homes, Version 2.5 

# Modular Home Completion Report

1 www . res e a rch - all i an c e.org Rev. 9/20 1 1 

## Instructions To qualify for ENERGY STAR, a home must meet t he National Program R e quirem e nts and the measures listed in these checklists:

• 

## Design Re qu irements Checklist (either Pre scriptive Path or Performance Path) • 

## Thermal Enclosure System Checklist • 

## HVAC Syste m Quality Installation Checkl i s t • 

## HVAC Syste m Quality Verification Checkl i s t • 

## Wa ter Man a gement System Checklist (or Indoor a i rPLUS Verification Checklist ) 1 

## Checklist ite ms flagged for field verification are ve rified by a R ater . 2 

## Raters are ex p ected to use their exp e rience a nd discretion to verify that the overall intent of each inspection checklist item has been m e t (i.e., identifying major defects that undermi n e the intent of the checklist i tem versus identifying minor defects that the Rater m a y deem acceptable). The column titled “N/A,” which denotes items t hat are “not applicab l e,” should be used wh e n the checklist ite m is not present in the home or conflicts with local require m ents. In the event that a Rater finds an item that is inconsistent with the intent of t h e inspection checklists, the home cannot earn the ENERGY STAR until the ite m is corrected. If correcti o n of the item is not possible, the home cannot earn the ENERGY STA R . The Rater is requi red to keep electron i c or hard copies of the comple ted and signed checklists. The signature of the HVAC technician is required if any of the HVAC equipm e nt specified on the HVAC System Quality Installation Checklist is install e d in the home. To receive t h e home labe l (s) and certi ficate, the Rater must send this **Modul a**  **r Home Completion**  **R e**  **port,** a copy of all completed and signed **Inspection Checklists**  a n d a **check for $50 per home*** (builder’ s report processing fee for home cert ificate and site label) to: **S y** **stems B**  **u ilding**  **Research A lliance**  **1776 Br o**  **ad w**  **a y** **, Suite**  **2205 N**  **e w**  **York, N**  **Y 10019** Please allow up to 5 days for d elive r y. For 2 - D a y delive r

y, enclose an additional **$20** S&H fee. * If this is a plant certification h o me , t h e following p r

ocessing fees apply (sele c t one):  **$150 pl a**  **nt certific a**  **tion home**  ($1 0 0 for plant QA label + $ 50 b u ilder ’ s fee)

- OR -  **$100 “temporarily**  **installed” plant certifi**  **c ation**  **home** 3 

### (for p l ant QA label only ) 

## Send **labels to**  **(check o**  **ne):**  

## Certifier / Rater Prima r y Contact Contact: 

###  

## Field Ins p ector / Tester Com p a n 

### y: 

###  

## Modular Plant Address: 

###  

## Modular Builder Ci ty 

### : 

###  

## Homeo wn e r State: Z i 

### p: 

###  

## Other (sp e cify in space at right) Pho n e or Ema i l:

1 

### A complet e d a nd si g n e d Ind o or airP L US Ve r ificati o n Chec kl i s t m a y b e co m p let e d b y t he R a ter and s u bm i tted in li e u of the Wa ter Management S ystem c hecklist. For m o re infor m ation, see the EPA we bsi t e: www . epa. g o v/i n doo rairp l u s . 2 

### T he term “Rater” refers to the pers o n comp le ting the third - p a rty in s pect i o n s requi red for q ualifi c ati o n. T h i s party m a y b e a certified H o me Energ y R a ter, Rati n g Field I n spector or BOP Inspector. 3 

### T e mporari l y i n stall e d homes must be re - in s pected b y a R a ter w h en i n stal l ed on t h e final home site a nd a n e w C o mp l e tion Re p o rt must be submitted a l o ng w ith the $50 report p roces s ing fee for the home certifi c ate and site l a b e l .OMB Control No. 2060 - 0586



# ENERGY STAR® 

# Qualified Homes, Version 2.5 

# Modular Home Completion Report

2 www . res e a rch - all i an c e.org Rev. 9/20 1 1 **Home A** **dd ress:**  **HOME I**  **D :**  **Ci t**  **y :**  **Stat e**  **: Zip:**  **Hom e**  **o w**  **ner Name:**  **Phon e**  **: 1**  **. C**  **O N**  **T A** 

**C T**  **I NFO**  **R M**  **A**

**T ION**  **Ce r**  **t i**  **fie r**  **/ R** **ate r**  **Pr i**  **m a**  **ry Con**  **ta c** **t F**  **i e**  **l d**  **I n**  **s p**  **e ct** **o r**  **/ T** **e ste**  **r** ( i f d i f fere n t fr o m P ri ma r

y C o nta ct) Compa n y Contact Nam e Compa n y Contact Nam e Addres s Address Ci ty State Zip Ci ty State Zip Phone F a x Phone F a x **Pl an**  **t an**  **d Q**  **C Sta** **ff B**  **ui l**  **d e**  **r** Corp o rate Paren t (i f applicab l e) Compa n y Contact Nam e Plan t N a me Q C Contact N a me Address Plan t Ci ty State Zi p Ci ty State Zip Phone F a x Phone F a x **H V** **A C**  **Co n**  **t r** **a c** **to r**  **/ T** **e ch**  **n i**  **c i**  **a n**  **H V** **A C**  **S y**  **s t** **em D**  **esigner** (if different from C ont. / T e c h.) Compa n y Contact Nam e Compa n y Contact Nam e Addres s Address Ci ty Stat e Zi p Ci ty Stat e Zip Phon e F a x Phon e F a x **2 .**  **W A**  **S T**  **H I**  **S H**  **O M**  **E T**  **E S**  **T E**  **D ?**  

##  **Y e**  **s** 

##  **N o**  I f N o, sk i p to qu esti

o n 5. **3 .**  **H O**  **US E**  **T I**  **GHTNESS a**  **)** Infi l trat i o n rate ( **≤ 6.**  **0** i n CZ s 1 , 2 **| ≤**  **5 .**  **0** i n CZs 3 , 4 **| ≤**  **4 .**  **0** i n C Zs 5 , 6 , 7 **| ≤**  **3 .**  **0** i n C Z 8) . **Me as**  **u r** **ed :**  **A CH5**  **0** ................... . 

##  **4 .**  **D UC**  **T T**  **I G**  **H TN**  **E S**  **S** (fil l i n an d chec k ON E ) **a )**  Du ct le aka g e to o utd o o r s ( **≤ 6**  **CF M2**  **5** P e rf

o rm an c e P at h ; **≤ 4**  **CFM 2**  **5** P res c ri p tive P at h) . **Me as**  **u r** **ed :**  **C FM**  **2 5**  **/ 1**  **0 0**  **s q**  **f t**  .. . 

##  * H o m e s wit h < 1,20 0 s q f t CFA : ≤ 5 C F M2 5 / 1 0 0 s q ft

**- O** **R -**  **b )**  Al l d ucts a n d ai r ha n dli n g e q uip m en t a re lo c at e d wi thi n t h e h o me’ s a i r a n d t h e rm a l b a rri e r s a n d en v elo p e l e aka g e h a s be e n te s ted t o be **≤ 3**  **. 0**  **A CH**  **5 0**  i n CZ s 1 , 2 **| ≤**  **2. 5**  **A C**  **H 5**  **0** i n CZs 3 , 4 **| ≤**  **2 .**  **0 A**  **CH 5**  **0** i n C Z s 5 , 6 , 7 **| ≤**  **1 .**  **5 A**  **C H5**  **0** i n CZ 8 . .................................................... . 

##  **5 .**  **Q U**  **A LI**  **T**

**Y A**  **SSUR A** **NC E**  **(Q A** 

**) L**  **A B**  **E L**  ( m us t c hec k ON E t o p as s ) **a )**  A n S B RA q ual ity ass u ra nce ( QA) mo d ul a r h o m e l a be l i s af fi xe d to h om e i n te ri o r a n d sign e d a n d dat e d b y a factor y r e prese n ta tive .......... . 

## 

**- O** **R -**  **b )**  T hi s i s on e of th e factor y’ s in i tia l thre e ce r

tifi c atio n homes . Th e p l a nt QA labe l wil l b e signe d a n d affi xe d wit h th e b l u e E N E RG Y STA R® Qualifi e d Ne w Ho m e s i te l a b e l (s e e inst ru cti o ns ) ............................................................................. . ................................................................. . 

##  **6 .**  **CE R** **TI F**  **I E**  **R /**  **R A** 

**T E**  **R EV** **A L**  **U A** 

**TI O**  **N** ( chec k ON E ) **a )**  PASS E S : N o di s cre p a ncies we re i de n tifi e d ...................................................................................... . ................................................................. . 

##  **b)** PASS E S : Mi n o r discre p anc i e s we re i d ent i fi e d an d repa i red , a n d t h e ho m e wa s re - in s pecte d ....................................................................... . 

##  **c)** FA I L S : Discre p a n cies a re d es c rib e d b el o w ........................................................................................................................................................ . 

##  **Si gn**  **a t**  **u r** **e o**  **f C**  **e r** 

**t i**  **f i**  **e r**  **/ R** **a t** **e r**  **: D**  **a t** **e :** 

### 3

www . res e a rch - all i an c e.org Rev. 9/20 1 1 EPA Form 5900 - 189 OMB Control No. 2060 - 0586 

# Modula r Hom e Com p letio n Report **PR O**  **B** 

### LE **M S**  **/ DI**  **S C**  **R** 

### E **P A** **NC** 

### I **E S**  **& R**  **E M**  **E D**  **I A**  

### TI **O N**  **A C**  

### TI **O N**  

### S **H O**  **M E**  **I D**  **: Ite**  **m No**  **. Di**  **s c**  **r e**  **pa n**  **cy**

**R e**  **m ed**  **i a**  **t io**  **n**

**Ite m**  **No .**  **Di s**  **c r** **e pa**  **n cy** 

**R e**  **m ed**  **i a**  **t io**  **n**

**Ite m**  **No .**  **Di s**  **c r** **e pa**  **n cy** 

**R e**  **m ed**  **i a**  **t io**  **n**

**Ite m**  **No .**  **Di s**  **c r** **e pa**  **n cy** 

**R e**  **m ed**  **i a**  **t io**  **n**

**Ite m**  **No .**  **Di s**  **c r** **e pa**  **n cy** 

**R e**  **m ed**  **i a**  **t io**  **n**

EPA Form 5900 - 189 The government estimates the average time needed to fill out this form is 0.25 hours and welcomes suggestions for reducing this effort. Send comments (referencing OMB Control Number) to the Director, Collection Strategies Division, U.S. EPA (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460 .