Common House Problems that Increase Energy Costs and Decrease Comfort
Inadequate Insulation
Air Leakage
Inefficient Heating Systems
Inefficient Central Air
    Conditioning Systems
Duct Leakage

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Your Information

* First Name:

* Last Name:

Are you a homeowner for the home at the address? Yes No

Street Address:

City:

State:

Zip:

Phone Number:
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* Email Address:


House Information

House Type:
(ex. Ranch)

# Levels: (excluding Basement/Attic)

Number of Units:
(ex. 1 family)

Square Footage:

Year Built:

# of Residents:

# of Years at Residence:

If it is a two family home, how many electric meters?


Health/Safety Issues

Does your home have asbestos insulation? Yes No Unsure

If yes, where?

Are there any mold or mildew issues? Yes No Unsure

If yes, where?


Heating

How many thermostats are in your home?

Are your thermostats programmable? Yes No

What temperature do you keep the thermostat set to in the winter?

What type of fuel do you use for heating? Oil Gas Electric Propane

What kind of distribution system heats your home?
Hot Water Baseboard Radiant Heat Forced Air

How old is the heating unit?

How old is your water heater?

Do you have more than one boiler/furnace? Yes No

If yes, how many?

What kind of fuel does your water heater use? Oil Gas Electric

What type of water heater do you have?
Tankless Coil Stand Alone Tank Indirect Instantaneous Water Heater

Is there natural gas in your home currently or on your street? Yes No


Cooling

Do you have central air conditioning? Yes No


Additional Comments or Questions:

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90 Pennsylvania Avenue, Massapequa, NY 11758-4978 | p. 516. 541. 1006 x14 | f. 516. 541. 2113

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