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_ . ; <br /> � <br /> i <br /> � <br /> p111N OR MODEL N0. DATED GEt�ERAL LONTRACTOR <br /> CONSTRUCTED FOR — ELECTRICAL CONTRACTOR _, <br /> . '� <br /> JOB LOLAT ION ,��� �� � ��``����� �� � NEW CONSTRUCT ION ❑ COt VERS Iz`! <br /> �-�, ,- _.T ��� t , <br /> � � , hen by <br /> I �'7C 1�.� ��� aQ �Itv <br /> (name of General Contractor, Ftnancing Ins U tution or uwner/ <br /> certify tha[ ihc insulation R-Values listed below (insulation material o .ly) <br /> will be installed and warrant th�t such insC�llation will actually be ma e <br /> at the loca[ion listed ahove. <br /> INSULATION <br /> Extcrior framc walls R � <br /> Exterior Concrete Walls above grade - R <br /> Cciling with vented a[tic above - R -�` � <br /> Ceiting open beam construction " R <br /> Floor over vented crawl space " R ( � <br />� Floo� over unven[ed unhcated area - R <br />� Floor - concrete slab (Perimeter) - R <br />� Concrete walls below grade _ R <br /> '_Duct Insulation � <br /> jMULTIPLE OCCUPANCY ��itUCTURES <br />� Exterior Exposures Sce Ahove) <br /> f Common walls separa[ing adjoinin9 ' R � � <br /> living units <br /> Common ceiling separating adjoining - R <br /> I living units R <br /> Common floors separating adjoining - <br />, living uiits <br /> ��Indicate insulation to be installed on ductwork or pipin9 located in •veited <br /> attics , crawl spaces, unheated garages and unheated basements when centr3l <br /> electric systems are to be installed. ` <br /> � � <br /> S IGN� � I ' ) L. �: '� ; r� I �;,;_�— <br /> (GePeral Contr ctor, Financing Ins i :ute <br /> or Owner) � <br /> BY " <br /> ITS • <br /> DATE <br /> SIGNED (Individual) <br /> DATE <br /> :_..., <br /> . '" <br /> ...... .. <br /> irnhY.'B�::ic-:-:':-'r.'r-::';-'n'Y.;::tiri.-:;::r.::n'c�t-,'•:,-;:u:r.l�:;i�-;'Yi,-.:';:Y:i"•"'Y'•:Y.Y:b'nb;�:dr,';:�b'r:'.�'ci;ir.'n:i;;:::.n;...,., <br /> ` RECEIVED BY � DATE _ <br /> State E1� , �cal Inspector <br />