HomeMy WebLinkAboutCertificate of Compliance (1987) This instrument Was Drafted By:
Rental Unit Energy Wisconsin Department of Industry,
DILHR USE Efficiency Standards Labor and Human Relations
Safety&Buildings Division
WeatherCertificate of Compliance P.O. l Box 7971,Madiso Program
TYPE OR PRINT USING BLACK INK (608) 66 067i Madison,WI 53707
Owner's Name(s): jj� Rental Building Location-Street Address Recording Information(Leave Blank)
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Street Address: City: i County:
(Oc Ai t 2 177 • pit . 0 J P:..v5 I-1 UJ!Vti!r-P.A t.50 _
City: State&Zip Code: Number of Rental Buildings Total Number of
t , f on Property: Rental Units: I
CDS 1-4- L-o LS F! (Al I Y�t • o
Owner's Telephone Number(include area code): Has this unit ever been issued Stipulation No.
CG 1'Y ) ,(.a` 1 j 0
aStipulation? ®Yes ❑No S-004O Ci
Legal Description of Rental Unit Property(may attach separate sheet):
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Certificate Instructions
This certificate is to be completed and signed by an inspector currently licensed by the Department of Industry,Labor and Human Relations for Rental Unit Energy
Efficiency inspection.•The original copy must be retained by the owner of the rental unit for use at time of transfer of ownership. NOTICE TO INSPECTORS: Per
ILHR 67.08(1);the yellow copy of this certificate must be promptly forwarded to the department upon rental unit'certification. - . -
CERTIFICATE CHECKLIST INSPECTION DATES
INSULATION LEVEL PASS DILHR Exemption Number NOT 1 (4-a.J'`i J
REQUIREMENT Fail Dates
Initial I Final DATE (or Comments) Applicable Accessible 2
1 Doors '-i_i`�i..",i 3
2 Windows a-ng-?7
3 g�_�% Section 101.122, Wisconsin
Caulking Statutes, requires that an
4 Weatherstripping = '.-?3-,}-? Energy Efficiency Cer-
5 BozSill R =11 R = -7-'o-?)-7 tificate, Stipulation or
6 Foundation and/or Crawl-Space R = R = * xA Waiver authorized by the
Department of Industry,
7 Forced Air Ducts R =S R = ' -Z-.-v'-7 Labor and.Human Rela-
8 Steam Heating Pipes R = R = iC tions (DILHR) must accom-
9 Hydronic Heating Pipes R = R = -< pany the documents of
10 Water Heater Jacket /-.r 2=-S 1 transfer at the time of
document recordation.
11 Domestic Water Pipes R ' 7 R= i-Z `8 7 This process is defined in
12 Heating Equipment Insp. -";1- -.- - ;1 Chapter ILHR 67, Wiscon-
13 Shower Flow Restrictors
-?...`:-5.- sin Administrative Code. A
orn-
14 Air Conditioner Covers ' Certificate isthe proof nf arils
� pliance with standards
15 Side Walls R = R = )"- of ILHR 67.05. In lieu of the
16 Access Panels and Doors R =i C( R = "J-L -..7 Certificate, the purchaser
17 Attic Insulation R =i R = i-.z;a-3-1 may accept responsibility
for compliance with either
18 Moisture Control:Attic&Crawl 1 -%e,--'7 , a Stipulation or a Waiver in
* Indicate Basement"Exception"Letter Here(Per ILHR 67.05(1)(d)(2.)) accordance with ILHR 67.08.
CERTIFICATE OF COMPLIANCE
The rental unit described above is certified as meeting the minimum rental unit energy efficiency standards of ILHR 67. Each applicable item on the
checklist complies with ILHR 67.05 or has been issued an exemption number. Certificate not valid unless signed and dated by the inspector.
Inspector's Name(Print) Inspector's Telephone Number Certified Inspector's Number
�D tAbA e£�� 1, i•f'✓i ' ? 641`l s)L 5 l.,_5-k -P`, B ' c Place DILHR
Transfer
Date Rental Unit Certified
n This Certificate is valid for 5 years from the date of the inspector's Authorization
C1 —2 &- v 7 , signature and is transferable during that period. Number Stamp
A Here
Inspector Signature /�
DILHR Transfer
,(r /� / •� i 4 (on white copy only)
.t�!,,f - if\ " y/l � Authorization Number:C-`—
DILHR SBD-7114(R.08/86) Copy Distribution: White-Owner; Yellow-DILHR; Green-Municipality/Inspector; Pink-Other