Weatherize Home Energy Questionnaire

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Miles Harvey
6 years ago
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Weatherize Home Energy Questionnaire Complete this form as best as you are able before requesting your free walkthrough with our participating contractors.

Mail completed form to: Vital Communities (Weatherize), 195 N Main Street, White River Junction, VT -OR- Complete this form online at VitalCommunities.

1 Weatherize Home Energy Questionnaire Complete this form as best as you are able before requesting your free walkthrough with our participating contractors. If you need assistance, contact x114. Mail completed form to: Vital Communities (Weatherize), 195 N Main Street, White River Junction, VT -OR- Complete this form online at VitalCommunities.org/Weatherize Basic Information Name: Physical address of your home: Mailing address, if different: Phone Number: Home Characteristics Home Type ( ) Single Family ( ) Mobile Home ( ) Townhouse/Duplex ( ) Duplex or Apartment Own or Rent? ( ) Own ( ) Rent Approximate square feet of heated space: Number of heated stories: ( ) 1 ( ) 2 ( ) 3 Year home was built: Age of roof: Type of roof: ( ) Metal ( ) Shingle ( ) Slate ( ) Other: House insulation level: ( ) Original Insulation ( ) Additional Insulation ( ) Well-Insulated Foundation: ( ) Full basement ( ) Crawlspace ( ) Slab ( ) Unfinished ( ) Gravel/Dirt

2 Is there attic access? ( ) Yes ( ) Yes, but bring a ladder Occupied? ( ) Year Round ( ) Seasonal ( ) Don't know Symptoms of an energy inefficient home (check all that apply) [ ] Ice-dams [ ] Frozen pipes [ ] Respiratory illness in the winter [ ] "Sweaty" windows in winter [ ] Mold/mildew [ ] Cold drafts [ ] Wet basement [ ] High energy bills [ ] Inefficient heating system Other energy efficiency concerns (or comments about the information provided above): Heating Information Heating System Type (Indicate primary and secondary if applicable) ( ) Warm air furnace (ducts distribute heated air) ( ) Hot water boiler (pipes carry heated water) ( ) Steam boiler (pipes carry steam) ( ) Woodstove ( ) Space heater/room heaters ( ) Radiant floor heating ( ) Air source heat pump ( ) Ground source heat pump ( ) Other: Heating Fuel Type (Indicate primary and secondary if applicable) ( ) Oil ( ) Wood (cord) ( ) Wood (pellets) ( ) Electricity (resistance/baseboard) ( ) Electricity (heat pumps) ( ) Kerosene ( ) Solar ( ) Other: Age of heating system(s) (in years): Average fuel price per unit (ex. $/gallon, $/cord) for heating system(s)?:

3 Heating Fuel Delivery Records Provide specific delivery dates and actual number of gallons/cords/tons/therms of fuel delivered during the past three years (NOT just an annual total). If you do not have this information, your fuel dealer should be able to provide it. If you heat with cord wood and do not have it delivered by the cord, please write in the estimated number of cords burned during each of the past three years. Delivery Date Primary Heating Fuel Amount of Fuel Delivered (e.g. 280 gallons ) Delivery Date Secondary Heating Fuel Amount of Fuel Delivered (e.g. 280 gallons ) Any comments regarding heating system information (e.g. delivery notes or clarifications): Estimated monthly electricity consumption for heating (in kwh), if applicable: Water Heating Water heating system type(s). Indicate primary and secondary, if applicable. ( ) Tankless coil direct inside boiler ( ) Storage tank indirect from boiler ( ) Storage tank with self-contained, vented burner ( ) Solar hot water What is your water heating fuel? Indicate primary and secondary, if applicable. ( ) On-demand or instantaneous ( ) Heat pump hot water heater ( ) Other: ( ) Oil ( ) Wood ( ) Electricity ( ) Kerosene ( ) Solar ( ) Other:

4 Age of water heating system(s): Water heater tank size(s): Is the water heater tank wrapped? ( ) Yes Are the water heater pipes wrapped? ( ) Yes Estimated monthly electricity consumption for water heating (in kwh), if applicable: Who is/are your fuel dealer(s)?: Do you have smoke detectors on each floor? ( ) Yes Do you have carbon monoxide detectors on each floor? ( ) Yes Oven fuel type: ( ) Electric Cooktop fuel type: ( ) Electric Dryer fuel type: ( ) Electric Do you have any renewable energy power systems installed at your home? ( ) Yes If yes, indicate what kind of system and its installed kw rating: Contractor Follow Up 1. We will send your Home Energy Questionnaire to one or more contractors of your choosing, who will follow up to discuss your options. Select your contractor on the next page. 2. If the contractor(s) believe your home is a good candidate for cost-effective home energy improvements, and you both feel their company is a good match for your needs, you can request a free home visit. After the home visit, the contractor will send you a proposal including a scope of work and estimated cost.

5 Select the Weatherize partner contractors to receive your Home Energy Questionnaire below. Building Energy White River Junction, VT Founded in 2007 BPI since 2002 Weatherization and Renovation of Montpelier Montpelier, VT Founded in 2008 BPI since 2008 van de Ven Construction Hartland, VT Founded in 2004 BPI since 2007 Vermont Foam Insulation Chester, VT Founded in 2006 BPI since 2008 Earthshare Construction Lebanon, NH Founded in 2011 BPI since 2015 Vital Communities cares about your privacy: Woodstock-Bridgewater-Pomfret Partner Contractors Building Energy is a comprehensive energy service company focused on reducing the carbon footprint of buildings through conservation, efficiency and renewable energy. We possess the vision and expertise to deliver green products and services in-house including energy audits, insulation, weatherization, solar systems and cold climate heat pumps. (BPI since 2002 while still part of sister company Northeast Construction) W.A.R.M. is a full service weatherization contracting business. We conduct the initial energy audit, perform all needed air sealing, utilize any insulation product desired by the client, diagnose and mitigate moisture issues, and provide all of the products and services needed to make your home more safe, comfortable, and energy efficient. van de Ven Construction focuses on small to medium size projects with a specialty in insulation and standing seam roofing. Our crew of six consists is a blend of licensed insulation installers, carpenters, and roofing specialists. We own spray foam and roofing equipment which eliminates the need to subcontract. Vermont Foam Insulation (VFI) started as a spray foam contractor in In the years since, we have grown substantially and now offer a full gamut of insulation services and energy efficiency contracting. Our goal is to increase the efficiency, durability, and comfort of each building that we work on. Earthshare Construction is a full service Green General Contractor. In addition to weatherization projects in both Vermont and New Hampshire, we also do new High Performance homes, additions, renovations, and remodeling. Our knowledge of home performance and building science allows us to deliver beautiful, comfortable, efficient, and durable projects. The information about your home and energy use provided herein will be shared only with the contractor(s) you have selected above. Your contact information and the fact that you have completed a Home Energy Questionnaire will be shared with Vital Communities and your town s volunteer team. Your town s volunteer team will be following your progress and reaching out with support and encouragement along the way. You can request at any time to be removed from your volunteer team s contact list. By submitting this form, you acknowledge that you have read and understand the above statement regarding how information from your Home Energy Questionnaire will be shared. Mail completed form to: Vital Communities (Weatherize) 195 N Main Street, White River Junction, VT The Weatherize Home Energy Questionnaire was produced by Vital Communities. For more information about Weatherize Upper Valley, visit VitalCommunities.org/Weatherize or contact the Energy Program at Energy@VitalCommunities.org or x114

Weatherize Home Energy Questionnaire

Weatherize Home Energy Questionnaire Complete this form as best as you are able before requesting your free walkthrough with our participating contractors. If you need assistance, contact Paige@VitalCommunities.org,