SALT LAKE COMMUNITY ACTION PROGRAM

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1 SALT LAKE COMMUNITY ACTION PROGRAM ENERGY AUDIT LSW: YES OR NO AIRSEALING FURNACE CREW NAME JOB# DATE ADDRESS PHONE CITY ZIP ENERGY AUDITOR AGE OF DWELLING STATE SAMPLE# # OF OCCUPANTS # OF COND. STORIES # OF BEDROOMS # OF COMB. APP. LIVING SPACE FLOOR AREA (SQ. FT.) PRE-RETROFIT BLOWER DOOR AIR LEAKAGE RATES MEASURED PASCALS ANTICIPATED PASCALS MAX COST OF AIR LEAKAGE REDUCTION $ ADDITIONAL COST ($) REPAIR H&S MISC. FUEL: ELEC PROPANE OIL WOOD NATURAL GAS BUTANE COAL SOLAR SYSTEM TYPE: FURNACE SPACE HEATER HEAT PUMP BOILER RESISTANCE ELEC. OTHER AIR CONDITIONING: ATTIC WINDOW OTHER TYPE: SWAMP REFRIGERATED DOMESTIC WATER HEATER: ELEC. BUTANE SOLAR NATURAL GAS PROPANE WINDOWS ORDERED: DATE: PO # HOW MANY DOORS ORDERED: HOW MANY Revised

2 SITE VIEW NOTES:

3 WINDOWS # Frame Glazing Shade Width Height Cost Location Window Code % Code Total Number Ordered PO Date Total Cost Code Number of doors Door Area (sq. ft.) Cond. Width (in.) DOORS Height (in.) *Ordering* Cost Comments Location Door code Total Number Ordered including water heater doors and furnace room doors, ect.. NOTES

4 WALLS Code Dir. Exp. Ext. Area Existing Insulation R Value Added Insulation Added Cost Comments Meas. # Insulation: Yes No Cost Existing Insulation: Inches R-Value Adding: Inches R-Value Cellulose Bags Fiberglass Loose Bags Fiberglass 16 on Center R-11 Fiberglass 24 on Center R-11 R-19 Rolls/Batts R-19 Rolls/Batts Gross Area Windows, Doors, Ect. Net Area Notes

5 UNFINISHED ATTIC AREAS Attic Code Joist Space Floor Area Existing Insul. Additional Insulation Depth Max. Depth (in.) (in.) Add. Insul. Cost Comments Meas. # FINISHED ATTIC Outer ceiling joist Area (sq. ft.) Existing Depth (in.) Additional insulation Additional Maximum Depth (in.) Add. Cost Comments Meas. # Collar beam Knee wall Roof rafter Roof Attic Insulation Yes No Cost Existing: In. R-Value Adding In. R-Value Cellulose Bags Fiberglass 16 on Center R-11 Fiberglass 24 on Center R-11 R-19 rolls/batts R-19 rolls/batts Attic Area Attic Venting: Existing vents Total Sq. In. Adding: Required vents Total Sq. In. TOTAL REQUIRED VETILATION SQ. INCHES NOTES:

6 FOUNDATION SPACES Foundation Space Code Floor Area Floor Insul. Perim. (Ft.) % Exp. Height % Exp. Insul. (R) Add. Cost Comments Meas. # Floor Insulation Yes No Cost Existing Insulation In. R-Value Floor Area Adding In. R-Value Cellulose Bags Fiberglass 16 on Center R-11 R-19 Rolls/Batts/Bags Fiberglass 24 on Center R-11 R-19 Rolls/Batts/Bags Perimeter Insulation Yes No Cost Existing Insulation In. R-Value Linear Ft. Adding In. R-Value Cellulose Bags Fiberglass 16 on Center R-11 R-19 Rolls/Batts/Bags Fiberglass 24 on Center R-11 R-19 Rolls/Batts/Bags NOTES:

7 COOLOING SYSTEM Unit Code Unit Size KBTU Whole House/ Room Seer Age/Yrs. Manufacturer Model Swamp or Refrigerated HEATING SYSTEM Primary System Fuel Location System Efficiency % of Heat Supplied Set Back Therm. Uninsulated Duct Uncond. Space Comments Secondary Primary System Information Manufacturer: Model: Input Rating (KBTU/H): Output Capacity (KBTU/H) Value: Annual Fuel Usage Efficiency: Pilot Light Present On in Summer IID Present Power Burner Present Vent Damper Present Recommended? Diameter (in.) Burn Flame Retention Head Present Recommended? General Condition Tune up/replacement Status Estimated replacement costs: Labor Equipment Comments: Combustion Air: H20 Input Rating Other H20 Info

8 Secondary System Info: Manufacturer: Model: Input Rating (KBTU/H) Output Capacity (KBTU/H) Value: Annual Usage Efficiency: Pilot Light Present On in Summer IID Present Power Burner Present Vent Damper Present Recommended? Diameter (in.) Burn Flame Retention Head Present Recommended? General Condition Tune up/replacement Status Estimated Cost of Replacement: Labor Equipment Comments Combustion Air: WATER HEATER H20 Input Rating: Gallons: Other H20 Info Combustion Air:

9 MATERIALS ORDERED ON HOME Units Special Instructions Caulk 25 year Cooler Lid Hugger Dryer Vent Kit Hard Pipe Smoke Detectors CO Detector Shower Head Plate Insulators H20 Jacket Pipe Insul.(linear ft.) 16 Fiberglass Batts Sheetrock Plywood Blueboard Compact Fl. Lights 2 x 4 s (ft.) Reflectix Raincap (ft.) Exhaust fans Setback Thermostat Door shoe Lock Reinforcer Other Notes: PLEASE SEE REVERSE SIDE FOR DOOR REPAIR AND REPLACEMENTS!!!!!!!!!!!!!!!!!

10 ***************************Door Repairs or Replacements:********************************* H20 Doors: 20 x x60 Trailer Door/Lock: Size (Hinge: L or R), Size (Hinge: L or R) Open: In or Out Open: In or Out 36 X X X 80 Interior Special door Pre-hung L or R SIZE: Pre-hung L or R SIZE: Weather Strip/Sweep Threshold L/C H/C Door lock Combo-lock Deadbolt Passage Handle Door Jamb (Lin. Ft.) Door Stop (Lin. Ft.) Brick Mold (Lin. Ft.) Door Casing (Lin. Ft.) Hinges Storm door repair: Closer Latch Stop Chain Plexi-glass FRONT BACK OTHER DOORS Crew Window Reglazing: Contracted Reglazing: # Width Height Location P.O. # Invoice Date Labor Glass Tax Total Contractor Phone # ************************************************************************ Insulation Units Yes No Attic Floor Perimeter Duct Insul.

11 ADDITIONAL FURNACE NOTES:

12

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