QA Inspection Form



Final Inspection Report Date ____________Agency _____________ Job# _________________ City: _______________________ County: ________________________Agency Auditor: ______________________________ Agency Inspector: ____________________________________Gas FORMCHECKBOX Electric FORMCHECKBOX Propane FORMCHECKBOX Solid FORMCHECKBOX (Type) ______________________________________________________Ranch FORMCHECKBOX 2 Story FORMCHECKBOX Tri-level FORMCHECKBOX Mobile FORMCHECKBOX Other: _________________________________________________Exterior Condition: Fair FORMCHECKBOX Good FORMCHECKBOX Excellent FORMCHECKBOX Notes: __________________________________________Brick FORMCHECKBOX Double Brick FORMCHECKBOX Siding FORMCHECKBOX Stucco FORMCHECKBOX Block FORMCHECKBOX Adobe FORMCHECKBOX Metal FORMCHECKBOX Other _________Comments: _________________________________________________ Year Built ______________ Multifamily? FORMCHECKBOX Owner FORMCHECKBOX Renter FORMCHECKBOX Landlord Contribution FORMCHECKBOX Completed FORMCHECKBOX In Progress FORMCHECKBOX Date Reported in BWR __________________________FILE REVIEW -Unit Assessed Using: FORMCHECKBOX Energy Audit (Name of Audit) ____________________________________________Waiver Granted For This Unit? FORMCHECKBOX YESNON/AWork Order/Building Weatherization Report FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX DOE Investment $____________ Owner Investment $_______________ Total Job $ _________Work Agreement/Permission Documentation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Lead-Paint Notification Documentation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Certified Renovator Documentation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Mold/Moisture Assessment FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Other Hazardous Notification FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX State Historic Preservation Docs (Pre-1951) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Combustion Appliance Testing: FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Comments: _________________________________________________________________________________________________Post Blower Door Results (@CFM 50) Pre #: _______ Mid #: _______ Post #: _______ BTL: __________Pressure Diagnostics (Pressure or ZPD) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Final Signed/Dated Inspection Form FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Agency Go-Back Required on this Unit? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Client Satisfaction Signed/Dated FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Minor Finding FORMCHECKBOX Major Finding FORMCHECKBOX Go-Back RequiredComments: ________________________________________________________________________________________________________________________________________________________________________________________________________________ON-SITE WORK ASSESSMENT – AIR SEALING -YESNON/AAir Sealing Performed: FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Window/Door weather-stripping FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Energy Related Repair ___________ FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Work Meets Standards: FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Minor Finding FORMCHECKBOX Major Finding FORMCHECKBOX Go-Back RequiredComments: _______________________________________________________________________________________________ATTICAttic Insulation Installed FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Pre-WX R: _____ Post-WX R: ______ # Bags: ________ (or other Quantity) ___________________________Good coverage & R-Value FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Good Patching/Plug work (ceiling drill & fill) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Good Patching/Plug work (Mobile Home Lid) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Insulation Certificate Completed & Posted FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Heat Source/ Vent Damming FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Attic Access Insulated and Secured FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Ventilation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Energy Related Repairs _______________________ FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Work Meets Standards: FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Minor Finding FORMCHECKBOX Major Finding FORMCHECKBOX Go-Back RequiredComments: ________________________________________________________________________________________________SIDEWALLS/KNEEWALLS -Sidewall Insulation Installed FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Drill & Fill Method FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Batt Method FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Other (Foam board, Spray Foam, etc.) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Pre-WX R: ______ Post-WX R: ______ # Bags: _______ (or other Quantity) ____________________________Plugs, Patching, & Painting Appropriate FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Kneewall Areas Insulated FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Insulation Certificate Completed & Posted FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Energy Related Repairs ______________________ FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Work Meets Standards: FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Minor Finding FORMCHECKBOX Major Finding FORMCHECKBOX Go-Back RequiredComments: _______________________________________________________________________________________________SUBSPACE - Slab FORMCHECKBOX Crawl FORMCHECKBOX Basement FORMCHECKBOX Foundation/Perimeter Insulation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Under-floor/Belly Insulation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Belly Patching (Mobile Home) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Basement Sidewall Insulation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Pre-WX R: ______ Post-WX R: ______ # Bags: ______ (other Quantity) _______________________________Vapor Retarder added; Coverage & Secure FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Energy Related Repairs _______________________ FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Work Meets Standards: FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Minor Finding FORMCHECKBOX Major Finding FORMCHECKBOX Go-Back RequiredComments: ______________________________________________________________________________________________HEATING, VENTILATION - YESNON/AHeating System Replacement (Efficiency) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Heating System Cleaning, Tune-Up/Filter FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Distribution System Modifications FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Duct/Boot Sealing FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Return Air Vents Sealed Off (Mobile Home) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Return Air Grills Added: FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Ventilation Installation/Modification FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Set-Back Thermostat Installation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Energy Related Repairs ______________________ FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Work Meets Standards: FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Minor Finding FORMCHECKBOX Major Finding FORMCHECKBOX Go-Back RequiredComments: _____________________________________________________________________________________________WINDOWS/DOORS -Number Of Windows Replaced: ____________ FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Number Of Storm Windows Installed: _______ FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Number Of Doors Replaced: _______ FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Energy Related Repairs ________________________ FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Work Meets Standards: FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Minor Finding FORMCHECKBOX Major Finding FORMCHECKBOX Go-Back RequiredComments: ______________________________________________________________________________________________OTHER MEASURES – Water Heater Tank Wrap FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Water Heater Pipe Wrap (1st 3 ft hot & cold) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Water Heater Door Insulated (Mobile Home) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Pipe Insulation added (correct size / diam?) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Low Flow Fixtures Installed: #__________ FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Lighting – CFLs Installed: #_____________ FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Fridge Replacement FORMCHECKBOX Meter FORMCHECKBOX Database FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Other Measures: _________________________ FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Work Meets Standards: FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Minor Finding FORMCHECKBOX Major Finding FORMCHECKBOX Go-Back RequiredComments: ______________________________________________________________________________________________HEALTH & SAFETY MEASURES -Attic H&S: FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Building Interior: FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Subspace: FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Building Exterior: FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX HVAC – Repair/Replacement (H&S) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Water Heater – Repair/Replacement (H&S) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Smoke /Carbon Monoxide Detectors: #______ FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Testing (Radon, Asbestos, etc) ________________ FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Other H&S Measures: __________________________ FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Work Meets Standards: FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Minor Finding FORMCHECKBOX Major Finding FORMCHECKBOX Go-Back RequiredComments: ________________________________________________________________________________________________OTHER ENERGY RELATED REPAIRS (Not noted elsewhere) -YESNON/AOther Repair Measures:________________________ FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX _________________________________________________________________________________________________________Measure(s) tied to for SIR: __________________________________________________________________________Work Meets Standards: FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Comments: _______________________________________________________________________________________________Agency Personnel Present During State Inspection: ___________________________________________________CEO Inspector ______________________________ Inspection Outcome: Pass FORMCHECKBOX Fail FORMCHECKBOX Go-Back FORMCHECKBOX ADDITIONAL COMMENTS/NOTES: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ................
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