*PA 145.91(e) requires this form to be completed in it’s ENTIRETY and be returned to Champion Modular Inc. and provided to the local AHJ*
INSTRUCTIONS
1. Set crew and builder are to fill out their respec ve sec ons.
2. Builder is to verify form is completed in it’s en rety.
3. Save completed form to an easy to access loca on.
4. Click the ‘mail to: Champion Modular’ link at the bo om of the form.
5. A ach completed form (subject line will be filled in automa cally).
6. Retain a copy for your records and furnishment to local AHJ.
*PA 145.91(e) requires this form to be completed in it’s ENTIRETY and be returned to Champion Modular Inc. and provided to the local AHJ*
FieldInstallationandJobsitePerformanceRecord
Revised8-15-24
House #:
Builder Name:
Builder Address:
Site Address:
Set Crew Company:
Crane Company:
Champion Modular Inc. Rep on Site
Weather Conditions:
Date of Set:
Builder Rep on Site:
Set Crew Lead:
Crane Size Used:
If raining or threat of rain, was house tarped: Yes No
Any damage upon unwrapping and prior to installation of modules must be communicated to Champion Modular Inc Service at 717-3452039 before proceeding with set.
Please sketch foundati on and note any imperfections in level, square or dimension issue causi ng an overhang at approximate location.
Please detail any issues with the foundation:
1. Type of Foundation: Block Poured Concrete Precast Wood
2. Exterior foundation walls water-proofed? Yes No
3. If Basement, is floor poured prior to set? Yes No
4. Basement/Crawl posts: All Installed Incomplete Explain:
5. Proper dozer or equipment on site to help move and position boxes? Yes No Size:
6. Jobsite Access: To Champion Modular Inc. specifications as noted in Champion Modular Inc. Installation Units toted to site
7. Units pulled together: Mate wall openings align Yes No within inches.
8. Gap at peak Yes No If NO, what is dimension of gap
9. End walls align: Yes No If NO, what is amount of offset
10. Floors level & bolted together: First Floor Yes No Second Floor Yes No
11. Roof tie-in & gable end panels: Complete Incomplete Explain:
12. Knee Walls: All Installed Incomplete Explain:
13. Collar ties: All Installed Incomplete N/A Explain:
14. Roof shingles & ridge Vent: All Installed Incomplete Explain:
15. Ice and water shield, valley flashing & ridge vent: All Installed Incomplete Explain:
16. Eave overhangs in correct position, roof sheathing and overhangs fastened properly, soffit baffles properly Installed Yes No
17. Mechanical fastening schedule installed per approved plans (check if completed): Thru-Bolts Shear Wall Connections Wind Strapping Perimeter Fastening Inter Module Connections Roof Strapping Knee Wall Strapping
18. Fire-stop insulation (if required): All Installed Incomplete Explain:
19. Marriage wall foam gaskets inspected and properly seals building envelope: Yes No
20. Air infiltration barrier is overlapped shingle style to correctly shed water: Yes No
21. Air Leakage test was conducted in accordance with N1102.4.1.2 and a written report of the results was signed by the approved third party conducting the test and provided to the code official: Yes No
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22. Set complete with Units weather tight: Yes No Explanation: 23. Explain any incomplete items/ visible damages/ or shortages:
If the floor insulation is not installed at the factory, floor or foundation insulation shall be installed on-site by the builder.
The builder is responsible for compliance with IRC requirements pertaining to window guards.
The Manufacturers data plate and insignia(s) are located SEE APPROVED PLANS
The Builder is responsible to complete the Air Barrier & Insulation Checklist and return it to the Manufacturer. (N/A for Tennessee)
The Builder is responsible to complete the Sprinkler System Inspection Checklist and return it to the Manufacturer per Sect P2904.8.1 –P2904.8.2 of the 2009, 2012, 2015, 2018, or 2021 IRC. (N/A for Tennessee)
The builder is responsible to test the Entire Hydronic Heating System hydrostatically at a pressure of not less than 100 PSI for a duration of not less than 15 minutes per IRC Chapter 21.
DCED Act 1 of 2011 – First floor wood floor joist assemblies using dimension lumber or structural composite lumber less than 2”x10” or open joist including finished basement and crawl space with storage or fuel-fired appliances shall be protected with ½ inch gypsum wallboard membrane, 5/8-inch wood structural panel membrane, or equivalent, on the underside of the floor framing member. This is builder responsibility. (N/A for Tennessee)
This form must be returned complete and signed by the Set Crew Lead and the Builder Representative and be sent to Champion Modular Inc. service at Fax (717)444-2452. The Set Crew by signing is confirming the accuracy of the above items listed and taking the responsibility for their work. The Builder by signing is confirming the accuracy of the above items and assuming responsibility for any incomplete work that is not explicitly covered by the Champion Modular Inc. Limited Warranty. Nothing contained herein shall make Champion Modular Inc. responsible for or legally liable for any defects in work or products supplied by other companies on-site. Champion Modular Inc. did not inspect materials or work supplied by others for quality.
(Builder Signature) (Builder Printed Name)
(Set Crew Lead Signature) (Set Crew Print)
Champion Modular Inc. certifies that Serial Number is not a manufactured home subject to the provisions of the National Manufactured Housing Construction and Safety Standards Act and is: (1) designed only for erection or installation on a site built permanent foundation (2) not designed to be moved once so erected or installed (3) designed and manufactured to comply with applicable standards, and (4) to the manufacturer’s knowledge not intended to be used other than on a site built permanent foundation.
This document must be signed by BOTH the Builder Representative AND the Set Crew Representative. Upon receipt of this form and review of the required signatures by Champion Modular Inc. Plant Controller, Champion Modular Inc. will pay the Set Crew the Set Fee listed on the first page of the home invoice.
Email to: Champion Modular Inc.
KHARTMAN@CHAMPIONHOMES.COM
NTOTTON@CHAMPIONHOMES.COM HFAWVER@CHAMPIONHOMES