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Customer Signature: Date: Primary Heating Fuel:❑Gas ❑Oil ❑Other Electric Provider:OJn' ❑Other Gas Provider:❑Columbia Gas ❑Liberty Utilities ❑ itil ❑Other _. Note any potential health or safety concerns and location. The ass Save Energy Specialist will verify your servation and determine any effect on the work scope. ❑ KnobfTube Wiring ❑ Combustion Sa Issues 8 Asbestos ❑ Moisture Structural Air Sealing Recommended?[]Yes ❑No Vapor Barrier'oYes❑No Whole Hou Fan?❑Yes❑No Attic Floored?❑Yes ❑Vo Locations❑Attic❑Basement❑Living space Insulation Location SgFt Recommended Type Densepack? Interior D+B? Access Needed? ❑Attic Flat ❑Batt[]Blown ORigi YesONo OYes ONO OYes ONO Kneewall(KW) Batt Blown Ri ' No Yes NO []Yeses ONo KW floor Batt®Blown® ' id BY H [:]Yes O No Yes❑NO OYes ONo KW slope Batt❑Blown igid ❑Yes No OYes[:]No ❑Yes ONO ❑ KW transition UBatt[]Blown Rigid OYes No []Yes[]No ❑Yes ONO Garage ceiling []Batt OBIo Rigid ❑Yes o ❑Yes ONO OYes ONO Bsmt ceiling [:]Batt❑Blo [:]Rigid ❑Yes O []Yes ONO []Yes❑No ❑Crawlspace ❑Batt❑B wn❑Rigid ❑YesONo ❑Yes[:]No ❑Yes ONo ❑Wall ❑Batt town❑Rigid OYes O No OYes[]No QYes❑No ❑Gable end ❑Batt Blown[]Rigid ❑Yes 0 N OYes[:]No OYes ONO Rim joist []Ba Blown[]Rigid OYes❑No Yes[:]No OYes ONo O Overhang OB OBlown ORigid []Yes O No Yes ONO OYes ❑No Existing: Proposed: Proposed Type Qty: Temp Sh athing Finished Roof Existing. ❑Roof❑Soffit Gable❑Ridge Need Propa Vents? O Yes O No If needed,check proposed types:❑Roof Soffit❑Gable❑Ridge .r..i :f' �. - f...a:- X V�^,'. ..'•:.. � `Y.: �� c 4`$°_Y 3,5.w. i ��+F�. ".s�.'n �n_.�. #F��k�: Contractor instructions Load referral document to your Sharepoint documents folder as REF_cust.last.name(e.g.,REF Smith). 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