HomeMy WebLinkAboutCertificate of Compliance (energy efficiency) - 09/25/1987 Rental Unit Energy This instrument Was Drafted By:
Wisconsin Department of Industry,
DILHR USE Efficiency Standards
Labor and Human Relations
Safety Buildings Division
Certificate of Compliance P.O. Box x 7971, M a d iso Program
TYPE OR PRINT USING BLACK INK (6 8)266 -0671 Madison, WI 53707
Owner's Name(s): Rental Building Location Street Address Recording Information (Leave Blank)
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Street Address: City: county:
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City: State Zip Code: Number of Rental Buildings Total Number of
7,-. 1
r on Property: Rental Units:
Owner's Telephone Number (include area code): Has this unit ever been issued Stipulation No.
a Stipulation? ❑Yes No SS_'Q4OE
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
REQUIREMENT Fail Dates
Initial 1 Final DATE (or Comments) Applicable Accessible 2
1 Doors 3
2 Windows
3 Caulking Section 101.122, Wisconsin
4 Weatherstripping ulkin Statutes, requires that an
Energy Efficiency Cer-
5 Box Sill R R tificate, Stipulation or
Waiver authorized by the
6 Foundation and /or Crawl-Space R R Department of Industry,
7 Forced Air Ducts R R Labor and Human Rela-
8 Steam Heating Pipes R R tions (DILHR) must accom-
9 Hydronic Heating Pipes R R pany the documents of
transfer at the time of
10 Water Heater Packet document recordation.
11 Domestic Water Pipes R R This process is defined in
12 Heating Equipment Insp. Chapter ILHR 67, Wiscon-
13 Shower Flow Restrictors sin Administrative Code. A
1 Certificate is proof of com-
4 Air Conditioner Covers
pliance with the standards
15 Side Walls R R of ILHR 67.05. In lieu of the
16 Access Panels and Doors R R Certificate, the purchaser
17 Attic Insulation R R may accept responsibility
for compliance with either
18 Moisture Control: Attic Crawl 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
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Date Rental Unit Certified Transfer
This Certificate is valid for 5 years from the date of the inspector's Authorization
2—? signature and is transferable during that period. Number Stamp
Inspector Signature l c DILHR Transfer Here
X0 ii I Authorization Number C T 14 3 ci (on white copy only)
DILHR SBD 7114 (R. 08/86) Copy Distribution: White- Owner; Yellow- DILHR; Green Municipality /Inspector; Pink -Other