One of the following certificates shall be completed and signed:

1. I ______ (owner) am aware that the Minimum Insulation Standards for Dwellings Converting to Gas or Electric Space Heat require my house to have storm doors, storm windows and at least R-19 (usually six inches) roof insulation. I certify that my building at ______ (location) meets those requirements, or that I have obtained a waiver; and I understand that should my building be found not in compliance, a 25-percent surcharge on my utility bill may be imposed or electric or gas service may be discontinued.

The undersigned attests that all statements and representations contained in this certificate are true and accurate.

Signature of Owner

Address

2. I have inspected the building at ______ (location) owned by ______ (owner) and certify that it meets the requirements of the Minimum Insulation Standards for Dwellings Converting to Gas or Electric Space Heat.

The undersigned certifies that a properly executed copy of this certificate will be delivered to the owner, and further attests that all statements and representations contained in this certificate are true and accurate.