EnergyMeasure HOME DATA COLLECTION FORM Section 1: General Information Customer Name: Site ID: Assessment Date: Street Address: City: State: Zip Code: Alternate Address: City: State: Zip Code: Telephone Number: Trade Ally: Email Address: Telephone Number: Natural Gas Provider: Account Number: Electric Provider: Account Number: Section 2: Building Model Year Built: Number of Bedrooms: Number of Occupants: Ceiling Height: Number of Floors Above Grade: Total Finished Floor Area: Total Finished Volume: Building Footprint Diagram (include orientation): 1
Section 3: Safety Aspects Item Yes No Notes: Gas Leaks: Asbestos: Knob and Tube: Moisture: Structural: Section 4: s/vaults Roof Pitch: <5/12 >5/12 Kneewall Location Area Square Enclosed Framing Feet Flat Wall Slope Yes No Yes No Insulation: Type, Inches and Condition Currently at Section 5: Ventilation Code: Yes No Type Type Type Gable Soffit Roof Gable Soffit Roof Gable Soffit Roof Size: Qty: Size: Qty: Size: Qty: Qty Bath Fans in House: Section 6: Eterior Walls/Overhangs Qty Need Venting to Roof: Qty Need Venting to Gable End: Qty Replace Hose: Siding Type Square Feet Framing Insulation: Type, Inches and Condition Section 7: Walls/Bo Sills Type of : Finished Partially Finished Unfinished Slab Location Sq/Lin Feet Framing Enclosed Yes No Height (ft) Eposed (ft) Insulation: Type, Inches and Condition Section 8: Windows/Doors Type of Window Material: Type of Door Material: Wood Vinyl Metal Type of Window Pane: Wood Vinyl Metal Type of Garage: Attached Garage Single Double Triple Low-e Notes: 2
Section 9: Blower Door/Air Flow (if the measured CFM50 is less than 70% of the Building Airflow Standard (BAS), mechanical ventilation must be installed.) Pre-Test CFM50: Post-Test CFM50: Rated Flow: Eisting Mechanical Ventilation: HRV ERV HVAC Return WH Ehaust Fan Notes: Notes: Eisting Mechanical Ventilation: HRV ERV HVAC Return WH Ehaust Fan Rated Flow: Section 10: Mechanicals Heating System 1 Heating System 2 Location: Location: Type of System Fuel Type Type of System Fuel Type Furnace Heat Pump Natural Gas Electric Furnace Heat Pump Natural Gas Electric Boiler (Wood, Propane, etc): Boiler (Wood, Propane, etc): Size (BTU s): Size (BTU s): Atmospheric Induced AFUE: Estimate Atmospheric Induced AFUE: Estimate Condensing Power Thermostat Temp Condensing Power Thermostat Temp Hrs: Hrs: Hot Water System 1 Hot Water System 2 Location: Location: Type of System Fuel Type Type of System Fuel Type Tank Tankless Coil Natural Gas Electric Tank Tankless Coil Natural Gas Electric Indirect On On Demand (Wood, Propane, etc): Indirect On Demand (Wood, Propane, etc): Size (gallons): Size (gallons): Atmospheric Induced Atmospheric Induced Condensing Power EF: Estimate Condensing Power EF: Estimate Air Conditioning 1 Air Conditioning 2 Location: Central Window Qty: Location: Central Window Qty: Size (tons): Size (tons): SEER: Actual Estimate SEER: Actual Estimate Thermostat Hrs. Thermostat Hrs. 3
Section 11: Combustion Safety Testing: Pre Test Result: Pass Fail Stop Notes: Eterior & Interior Inspections Eterior Temperature: Degrees F Current Thermostat Reading: Degrees F Eterior Reading Interior Readings Highest Ambient CO ppm ppm Gas Pipe Leak NA No Yes NA No Yes Zone Locations CAZ Pressure Diagnostics (see attached worksheet for step-by-step breakdown) Baseline Pressure WRTO Pa Pa Pa Worst Case Pressure WRTO Pa Pa Pa Pressure Difference Pa Pa Pa Meets BPI Standards Yes No Yes No Yes No Appliance Combustion Safety Tests (Fire smallest appliance first, then larger appliances, then combined) Draft w/ Passed Undiluted Draft Heating Location Spillage CO (Pa) System(s) Test (ppm) Firing (Pa) Ambient CO (ppm) Test Result Yes No Pass Fail DHW Heating System 1 Heating System 2 Oven Kitchen N/A N/A N/A Commonly Vented Appliances (If any of the appliances fail the spillage test under WCD, re-test under natural conditions and record the results below. Re-test draft and CO) Passed Draft w/ Heating Undiluted Ambient Appliance Spillage Test Draft Test Result System(s) Firing CO CO (Pa) Yes No (Pa) (ppm) (ppm) Pass Fail App: App: App: 2013 Focus on Energy MM-6120-0513 4
EnergyMeasure HOME DATA COLLECTION FORM Reference Material CAZ Worst Case Depressurization Worksheet (optional) Follow the worksheet to figure out the worst case depressurization. Be sure to enter lines 1, 5, 6 and 7 on page 4 (CAZ Pressure Diagnostics section). Number Step Reading 1 2 3 4 5 6 7 8 Create baseline winter conditions (eterior windows/doors shut, fireplace damper closed, interior doors open, all ehaust appliances off). If using baseline features on manometer, do so now. Record your baseline reading here and on page 4. Turn on all ehaust appliances in home, closing interior doors with no fans. (DO NOT turn on whole house fans or mechanical attic vents). Record pressure reading. Turn on furnace air handler. Check for system integrity and verify all registers are open and unobstructed. Record pressure reading. Only if line 3 is more negative, go back and readjust interior doors: Measure the pressure difference between main body and the room you are testing. If negative and the smoke moves into the room, OPEN door. If positive and the smoke moves towards the hall, CLOSE door. Start with furthest door, working back to CAZ. Record pressure reading. Record the most negative reading from lines 2, 3 or 4. Record this on page 4 as well. Subtract the reading in line 5 from the reading in line 1. This pressure difference is the worst case depressurization. Record this on page 4. Compare the worst case depressurization reading on line 6 with BPI s CAZ Depressurization Limit Table. If it fails, notify the customer with a disclosure form. Make recommendation to provide makeup combustion air to the CAZ in order to bring the depressurization within acceptable limits. Maintaining the house under worst case conditions, proceed to test the appliances. Pass NA Fail Ranges and Ovens (continually monitor ambient CO levels during test) 1 Remove any items/foil in or on oven/range top. 2 Make sure self-cleaning features are not achieved. 3 Test oven in vent sleeve, before dilution air. A B If 100 ppm to 300 ppm as measured: You must install a carbon monoide detector and recommendation for service must be made to the consumer. To Outside 4 If greater than 300 ppm as measured: The unit must be serviced prior to work. If greater than 300 ppm after servicing, ehaust ventilation must be provided with a capacity of 25 CFM continuous or 100 CFM intermittent. To Flue 5
Combustion Safety Test Action Levels CO Test Result* And/Or Spillage & Draft Test Results Retrofit Action 0 25 ppm And Passes Proceed with work 26 100 ppm And Passes 26 100 ppm And Fails at worst case only 100 400 ppm Or Fails under natural conditions >400 ppm And Passes >400 ppm And Fails under ANY condition *CO measurements for undiluted flue gases at steady state. CAZ Depressurization Limits Recommend that the CO problem be fied Recommend a service call for the appliance and/or make repairs to the home to correct the problem(s) Stop Work: Work may not proceed until the system is serviced and the problem(s) is/are corrected Stop Work: Work may not proceed until the system is serviced and the problem(s) is/are corrected EMERGENCY: Shut off fuel to the appliance and have the homeowner call for service IMMEDIATELY Venting Condition Limit (Pascals) Orphan natural draft water heater (including outside chimneys). -2 Natural draft boiler or furnace commonly vented with water heater. -3 Natural draft boiler or furnace with damper commonly vented with water heater. -5 Individual natural draft boiler, furnace or domestic hot water heater. -5 Mechanically-assisted boiler or furnace commonly vented with water heater. -5 Mechanically-assisted boiler or furnace alone, or fan-assisted DHW alone. -15 Chimney-top draft inducer (Ehausto-type or equivalent); High static pressure flame retention head oil burner; Direct-vented appliances/sealed combustion appliances. Acceptable Appliance Spillage Periods Appliance Type -50 Spillage Test Period (minutes) Water Heater, Gravity Furnace, Boiler 1.0 Space Heater 1.0 Forced Air Furnace 1.0 Acceptable Draft Test Ranges Outside Temperature (degree F) Draft Pressure Standard (Pa) <10 Degrees -2.5 10 90 Degrees (T_out /40) 2.75 >90 Degrees -0.5 6