City of Galveston
City of Galveston - Building Division
P.O. Box 779
Galveston, Texas 77553
Email: planningcounter@cityofgalveston.org
Phone: 409-797-3660
INDEPENDENT THIRD-PARTY TECHNICIAN REGISTRATION FORM
TECHNICIAN INFORMATION
Name:___________________________________ Drivers Lic. No.___________ State: _______
Address (No P.O. Box)__________________________________ Phone Number: (___)____________
City: ___________ State: ____ Zip Code: _______ Email Address: __________________________
BUSINESS OR COMPANY INFORMATION (If any information is different)
Company’s Name: _________________________________ Phone No: (___)_______________
Business Address (No P.O. Box)______________________ Fax: No: (___)_______________
City: ___________ State: ____ Zip Code: ____________ Email Address: ______________________
PROVIDER INFORMATION
(if technician is, or works under supervision of HERS rater or provider)
Name:___________________________________________
_
Phone No: (___)______________________
Business Address (No P.O. Box)______________________ Phone No: (___)______________________
City: ___________ State: ____ Zip Code: ____________ Email Address: _______________________
CERTIFICATION
Check one as
Appropriate
Type of Certification Certificate Number
Home Energy Rating System/Certified Home Energy Rater ___________________
Home Energy Rating System/Certified Field Inspector ___________________
Building Performance Institute/Certified Building Analyst ___________________
ACKNOWLEDGEMENT
I am trained and certified to perform leakage testing for residential energy efficiency. I attest that I am not affiliated with a builder
or construction company and that I perform diagnostic testing (blower door, duct blaster) as an independent third-party agent. I
understand that the City of Galveston will confirm my status as a rater through my provider.
I acknowledge that the City requires only leakage testing for new residences and additions of 500 square foot or more. I understand
there is no requirement to rate the entire structure but only to perform the duct blaster and/or blower door tests as applicable for the
energy code compliance method used. Results shall be provided with volume calculations, targets, and actual performance.
Signature: _______________________________________________ Date: ___________________
FOR OFFICIAL USE ONLY
Energy Testing Technicians registration No: _____________________ Expiration Date: ______________
s\planning\building division\building division forms\contractor related\energy technician application\8-10-2010
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