Fillable STATEMENT OF SYSTEM COMMISSIONING (Brunswick County)

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STATEMENT OF SYSTEM COMMISSIONING (Brunswick County)

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BROWSE BRUNSWICK COUNTY (NC) FORMS

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2018 NORTH CAROLINA ENERGY CONSERVATION CODE C-79
APPENDIX C1
STATEMENT OF SYSTEM COMMISSIONING
Part 1: Mechanical
Project Name: _______________________________________________________________________
Project Location: _____________________________________________________________________
In my professional opinion, the HVAC systems have been installed in substantial compliance with the
intent of the approved project plans and specifications based on a site observation performed and upon
review of the following:
Notes:________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_______________________________
List of Deferred Tests:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_______________________________
Name: _______________________________________________
Signature: ____________________________________________
Date: ________________________________________________
YES NO
NOT
REQUIRED
ITEMS COMMENTS
Testing and Balance Reports
Operations and Maintenance Manuals for HVAC
HVAC Equipment
HVAC Controls and Operational Sequences
Seal Above:
APPENDIX C1
C-80 2018 NORTH CAROLINA ENERGY CONSERVATION CODE
Part 2: Service Water Heating
Project Name: ________________________________________________________________________
Project Location: ______________________________________________________________________
In my professional opinion, the service water heating systems have been installed and are in substantial
compliance with the intent of the approved project plans and specifications based on a site observation per-
formed and upon review of the following:
Notes:________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_______________________________
List of Deferred Tests:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_______________________________
Name: _______________________________________________
Signature: ____________________________________________
Date: ________________________________________________
YES NO
NOT
REQUIRED
ITEMS COMMENTS
Manuals for Service Water Heating
Service Water Heating Systems
Seal Above:
APPENDIX C1
2018 NORTH CAROLINA ENERGY CONSERVATION CODE C-81
Part 3: Electrical
Project Name: ________________________________________________________________________
Project Location: ______________________________________________________________________
In my professional opinion, the lighting systems have been installed and are in substantial compliance with
the intent of the approved project plans and specifications based on a site observation performed and upon
review of the following:
Notes:________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_______________________________
List of Deferred Tests:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_______________________________
Name: _______________________________________________
Signature: ____________________________________________
Date: ________________________________________________
YES NO
NOT
REQUIRED
ITEMS COMMENTS
Manuals for Lighting Systems
Lighting Equipment
Lighting Controls and Operational Sequences
Seal Above:
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STATEMENT OF SYSTEM COMMISSIONING (Brunswick County)

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Completed 1 April 2021

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