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2
Claim #:
I. GENERAL INFORMATION
Commissioning Party’s Name:
Address:
City: State: Zip:
Contact Number: Email:
Homeowner/Building Owner’s Name:
Address:
City: State: Zip:
Contact Number: Email:
Flooring Contractor’s Name:
Address:
City: State: Zip:
Contact Number: Email:
General Contractor’s Name:
Address:
City: State: Zip:
Contact Number: Email:
Manufacturer’s Name:
Address:
City: State: Zip:
Main Contact Info: Title:
Contact Number: Email:
Jobsite Visit Date: Time:
II. JOBSITE INFORMATION
Residential Commercial New Construction Remodel
Single Family Duplex Condo Apartment Complex
OCCUPANT INFORMATION# of Children: Pets:# of Adults:
Retailer’s Name:
Address:
City: State: Zip:
Main Contact Info: Title:
Contact Number: Email:
Age of Building: Yes NoOccupied: # of levels:
Date Sold to End-user:Date of Installation:Date Complaint First Noticed: Reported to: Unusual Events:Cleaning Products/Methods Used:
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Claim #:
III. STATEMENT OF CONCERN
IV. CLAIM HISTORY
Date Reported: Date Occupied:
How Often:
Moisture Content at Installation: Moisture Meter Type: Name:Model: Meter Species Correction: Moisture Content Readings (include a range, average, and number of tests performed):
JOBSITE CONDITIONS AT INSTALLATIONProcess of Acclimation:
During Install:
Temperature (Interior)During Install:RH (Interior)During Install:HVAC Operational During Storage: Yes Location and Description of Storage Area at Jobsite:
No Yes No
Date of Completion: Date Delivered to Jobsite:
4
Claim #:
Nail Glue Float
INSTALLATION METHOD
Floating Installation Method Locking Mechanism Edge GluedAdhesive Used: Perimeter Expansion: Type of Underlayment Used: Floor Measured for Flat: Yes NoMethod Flatness Measured: Tolerance: 3/16” in 10’ 1/8” in 6’
Movement within Flooring System: Additional Installation Information:
+/–+/–
IV. CLAIM HISTORY (CONTINUED)
+/–
Length: Gauge: # of Nailers used on the floor install:
Yes No
3/16” in 6’
Nail Installation Method
Fastener Type: Pneumatic Air Pressure Setting: Type/Brand of Nailers:Type of Underlayment Used: Floor Measured for Flat: Method Flatness Measured: Tolerance: 1/4” in 10’ +/–
Application Method:
New
Location(s):Isolation
Spread Rate:
Age of Concrete:+/–
Used# of Trowels Used: Subfloor Measured for Flat: Yes No Method Flatness Measured: Tolerance: 3/16” in 10’ +/– 1/8” in 6’ Construction Joints present:
Type: Construction: Control Method addressed at installation:
Amount of time before traffic was allowed on installed floor: Movement within Flooring System: Additional Installation Information:
Glue-Down Installation MethodAdhesive System Used (type/brand): Moisture Control System Used (type/brand): Trowel Used (type):
Movement within Flooring System: Additional Installation Information:
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Claim #:
V. PHYSICAL DESCRIPTION
NEW CONSTRUCTION INFODate Home Completed: Date HVAC Fully Operational:
Condition of Existing Floor:CONCERNS
General Throughout Stabilized
Localized Progressing
Improving Other
Square Footage Delivered: % of Floor Affected: Total Sqft Material Installed:
FLOORING
Additional Info on Flooring Container:
Manufacturer:
Production date/Lot #: Sqft per Container:
ROOMS BEING INSPECTED
Entry: sqft Kitchen: sqft Hall(s): sqft Great Room: sqft Living Room: sqft Dining Room: sqft Nook: sqft Pantry: sqft
Formal: sqft Study: sqft Library: sqft Powder Bath: sqft Bath 1: sqft Bath 2: sqft Bath 3: sqft Bath 4: sqft
Bath 5: sqft Master Bedroom: sqft Bed 1: sqft Bed 2: sqft Bed 3: sqft Bed 4: sqft Bed 5: sqft Other Rooms: sqft
Home Faces: North South East WestEXTERIOR EVALUATION
Relation of Lot to Street: Relation of Lot to Neighbors:Lot Drainage Away from Foundation: Yes No Slope Angle Measurement: Gutters/Downspouts: Yes No Roof Overhang: Yes NoSoil Damp at Foundation: Yes No
Shrubs/Flowers/Planter Boxes at Foundation: Yes NoSprinklers/Irrigation: Yes No Established Landscape: Yes NoWater Source/Swimming Pool Nearby: Yes No Proximity to Structure:
Building is over: Basement Crawlspace Slab
Window-wells: Wet Dry Signs of Moisture Yes No
Visible Cracks in Foundation: Visible Exterior Damage:Yes No Yes No
Species:Engineered Solid
Strip (Width: )Plank Parquet
UnfinishedFactory Finished
Flooring thickness:
Approved Over Radiant Heat: Yes No Approved Below Grade: Yes No
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Claim #:
Has floor been through full cycle of seasons? Yes No
Thermostat Control Settings:
Programmable: Yes No Data Logger: Yes No
Operating: Yes NoHumidification/Dehumidification System: Yes No
Date of Last Service (if known):
V. PHYSICAL DESCRIPTION (CONTINUED)
Location of Heating: Above Below Floor Baseboard
Type of Heating System:Forced Air Electric Radiant
Wood Burning Stove Radiator Baseboard
Other: Type:
HVAC EVALUATIONHVAC System Operating: Yes No
Type Of Cooling System:
Central Air Conditioning Portable Air Conditioning Swamp Cooler
Underfloor Exhaust Fan
Other: Type:
Audible Noises – Locations:
Traffic Use: High Average LowAny Special or Unique Use:
Other Trades | Schedules prior to, during or after installation: SPECIAL CONSIDERATIONS
Please include reference to supporting audio/video.Description of Sound:
Factory Finish Issues:
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Claim #:
V. PHYSICAL DESCRIPTION (CONTINUED)
BELOW FLOORING SYSTEM EVALUATION
Crawl Space Evaluation
Open-Air Crawlspace Wall-Vented Crawlspace
Enclosed Crawlspace Ground is Dirt, Concrete, Gravel, Other
Standing Water Present: Yes NoCondensation Present: Yes No
Alkali/Discoloration on Foundation Walls: Yes No
Vapor Retarder Present: Seams Overlapped Yes No inches
Seams Sealed: Method of Sealing:Yes No
Percent of Ground Covered: %Plastic Taped up Foundation Walls: Yes No
Insulation on Foundation Walls: Yes NoInsulation between Joists: Yes No
Number of Vents: Open/Closed: Vents Present: Yes No
Humidistat Installed: Yes No
Basement Evaluation
Basement Finished/Unfinished: If Finished, Date Completed: Walk Out: Yes NoSpecify Side(s) below ground level: North South East WestWall Cracks Present: Location:Yes No
Operating: Sump Pump: Yes No Yes NoYes NoHVAC Vents Open to Basement:
Signs of Moisture Damage: Floor Stains: Yes NoPeeling Paint: Yes NoGapped Trim or Moldings: Yes NoRusty Nails: Yes No
Wood Subfloor EvaluationType of Wood Subfloor:
19/32” PS-1 CDX Plywood 19/32” PS-2 CDX OSB 23/32” PS-1 CDX Plywood 23/32” PS-2 CDX OSB
7/8” Plywood or OSB 1” x 6” Solid Board Particle Board
Joist Type:Joist Spacing:Visible Rot: Yes No
Other
Yes
Concrete Slab Evaluation:Relation of Slab Surface to Exterior Soil Line: inchesNormal Weight Concrete (min 3000 psi): UnknownNoLight Weight Gypsum Concrete: UnknownYes NoPre-Tension/Post-Tension Slab: UnknownYes NoMoisture Retarder used Below Slab: UnknownYes No
SUBFLOOR EVALUATION
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Claim #:
HVAC Testing: Temperature: F/C Relative Humidity: %
VI. TESTING
Other Moisture Tests Conducted:
JOBSITE CONDITIONS AT INSPECTION
Moisture Meter Type: Name:Model: Meter Species Correction:
High Reading: Low Reading:
Average Moisture Content at Inspection:Floor: Top: Back:
FLOOR TESTSAverage Measurement of Individual Boards Face Width:
Average Measurement of Gaps:
Does pattern of issue convey a relationship with building mechanical systems or foundation or slab cracks and/or settlement? Yes No
Cupping Measurements: Buckling Measurements:
Measurement Across 10 Boards: Average:20 Boards:
Meter Used:
Number of Readings: Locations of High Readings:
Moisture Test Results (include number of tests performed):
Comparison Readings (baseboards, trim, door, cabinets, etc.):
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Claim #:
VI. TESTING (CONTINUED)
SUBSTRATE TESTING:
Wood Subfloor TestingMoisture Content Readings: High Reading: Low Reading: Moisture Test Results (include an average and number of tests performed):
Moisture on UndersideMoisture on Top Moisture in Core
Joist Moisture Content:
Moisture Meter Type: Name:Model:Meter Setting:
Comparison Readings (baseboards, trim, door, cabinets, etc.):
Meter (ASTM 2659) Other
Concrete Slab Testing (uninstalled f looring or destructive testing only) Moisture Test(s) Required by Flooring Manufacturer:
RH (ASTM 2170) Meter (ASTM 2659) CaCl (ASTM 1869) Other
Results of Required Test(s): Number of Tests: Location of Tests:
Moisture Test(s) Required by Adhesive Manufacturer:
RH (ASTM 2170) CaCl (ASTM 1869)Results of Required Test(s): Number of Tests: Location of Test(s):
Other Moisture Test(s) Conducted:
Results of Required Test(s): Location of Test(s):
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Claim #:
Distance from Ground to Underside of Joists: inches/cm
Joist Moisture Content: Moisture Content Underside Subfloor:
Meter Used:
Crawl Space TestingTemperature: F/C Relative Humidity: % Meter Used:
Basement Testing
Temperature: F/C Relative Humidity: % Meter Used:Moisture Content Underside Subfloor:Joist Moisture Content:
Meter Used:
VI. TESTING (CONTINUED)BELOW FLOORING SYSTEM TESTING:
ADDITIONAL TESTING INFORMATIONPlease list all of the tests performed along with the results and tools used for the tests. Add reference to supporting photos.
15
Claim #:
Please list the source from which standards were applied. Then copy/paste specific areas ofcontent that were used in the process.
VII. APPLIED INDUSTRY STANDARDS: