Appilcation for State Electrical License

OFFICIAL USE ONLY June 2014 IOWA STATE ENERGY CODE STATEMENT OF REVIEW FORM IOWA STATE FIRE MARSHAL OFFICE STATE BUILDING CODE BUREAU 215 EAST 7TH STREET DES MOINES, IA 50319 Business Hours: 8am - 4:30pm M-F Phone: 515-725-6145 Fax: 515-725-6172 Email: [email protected] Building Code Bureau: www.iowabuildingcode.org State Fire Marshal: www.dps.state.ia.us/fm/index.shtml Please submit this completed form with applicable energy calculations or software printouts along with fees to the SFM’s address listed above. This form is required for new buildings or new additions to buildings per Iowa Code 103A and Administrative Rule 661-303.1(3). Project Name: Project Street Address: City: Iowa, Zip: County Name: Architect/Engineer Firm Name: Phone: A/E Responsible Designer’s Name: IA License #: A/E Firm’s Street Address: City: State: Zip: A/E Contact Email: Indicate type of building project: Residential Building (R2,R3 & R4 occupancies 3 stories or less above grade) Commercial Building (All other occupancies not considered residential buildings per IECC) Indicate the climate zone for this project: (IECC Climate Map): 5 6 Indicate below the method used to determine compliance with State Energy Code-2014 International Energy Conservation Code (IECC). http://www.legis.state.ia.us/aspx/ACODOCS/DOCS/661.303.pdf

IECC 2012 or ASHRAE 90.1 2010 Prescriptive Provisions (For Residential or Commercial Buildings). COMcheck ™ (US DOE) - http://www.energycodes.gov/comcheck/ IECC C402.1.2 or ASHRAE 90.1-5.2.1 REScheck ™ (US DOE) - http://www.energycodes.gov/rescheck/ IECC R402.1.4 IECC 2012 – Performance Provisions for Residential Buildings (US DOE) IECC Section R405 ASHRAE 90.1 2010 – Performance Provisions for Commercial Buildings (US DOE) Chapter 11 (Only)

I certify to the best of my knowledge that all the information submitted on this form and supporting documentation is accurate and true and that this engineering document was prepared by me or under my direct supervision, and that I am duly licensed professional engineer or architect under the laws of the State of Iowa.

$ 25 Filing Fee required with this form payable to State of Iowa Treasurer Responsible Designer’s Signature: Engineer or Architect Seal

License/Registration Expires: