HomeMy WebLinkAboutCertificate of Compliance (energy efficiency) - 09/25/1987 This instrument Was Drafted By:
Rental Unit Energy
DILHR USE Wisconsin Department of Industry,
Efficiency Standards Labor and Human Relations
Safety Buildings Division
Rental Weatherization Program
TYPE OR PRINT USING BLACK INK Certificate of Compliance P.O. Box 7971, Madison, WI 53707
(608) 266-0671
Owner's Name(s): Rental Building Location Street Address Recording Information (Leave Blank)
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Street Addr ss: t '1 City: County:
f C' C i 7 AVF- C_ 3 1 .0S /-4 VVI NJ nJ A
City: State Zip Code: Number of Rental Buildings Total Number of
i` on Property: Rental Units:
Owner's Telephone Number (include area code): Has this unit ever been issued Stipulation No.
4 n `7 a Stipulation? -1
Z Yes No S -L) 0 4 0
Legal Description of Rental Unit Property (may attach separate sheet):
Lam; GB A 1 Ti (3 F C191 LOZ 1-4
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
REQUIREMENT INSULATION LEVEL Fail Dates PASS DILHR Exemption Number NOT 1
Initial I Final DATE (or Comments) Applicable Accessible 2
1 Doors f, 3
2 Windows .y Z. S
3 Caulking Section 101.122, Wisconsin
-11 Statutes, requires that an
4 Weatherstripping h; =i_Z -;31 Energy Efficiency Cer-
5 Box Sill R R ,-ii-.37 tificate, Stipulation or
6 Foundation and /or Crawl-Space R R *0. Waiver authorized by the
7 Forced Air Ducts R R Department of Industry,
Labor and Human Rela
8 Steam Heating Pipes R R tions (DILHR) must accom-
9 Hydronic Heating Pipes R R y pany the documents of
10 Water Heater Jacket transfer at the time of
I(-a7 document recordation.
11 Domestic Water Pipes R R =..Y c?-`' 5 -S J This process is defined in
12 Heating Equipment Insp. Chapter ILHR 67, Wiscon-
13 Shower Flow Restrictors ?_Z( -;3 "J sin Administrative Code. A
14 Air Conditioner Covers Certificate is proof of com-
15 Side Walls R R pliance with the standards
of ILHR 67.05. In lieu of the
16 Access Panels and Doors R R d 37 Certificate, the purchaser
17 Attic Insulation R R 1( .3-7 may accept responsibility
18 Moisture Control: Attic Craw! I; 7 for compliance with either
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) i-' p� Inspector's Telephone Number Certified Inspector's Number
to t h i„ (M f." t— FC_. t. t`4 J 0 4',, j,_ Place DILHR
Date Rental Unit Certified Transfer
4 This Certificate is valid for 5 years from the date of the inspector's Authorization
1 C� 7 C— ej 7 signature and is transferable during that period. Number Stamp
Inspector Signature /1 DILHR Transfer Here I
I y�, 1 4 Z 4 c 3 (on white copy only)
Authorization Number C-
DILHR SBD 7114 (R. 08/86) Copy Distribution: White- Owner; Yellow- DILHR; Green Municipality /Inspector; Pink -Other
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