Green Building Materials Certification Form – Fill Out and Use This PDF

CONTRACTOR:	___________________________________________	SPEC SECTION(S):	______________________________________
CONTACT NAME:	___________________________________________	TEL. NO: ______________________________ SUBMITTAL NO:	______________________________________

Contains

For wood

Material

Recycled

Contains

products [Y/N]

VOC Content

7

Total

COST

Content?

Manufacture

Raw Materials

Rapidly

[adhesives,

Product

Vendor or Manufacturer

Installed

[excluding

Location 3

Origin 4

Renew-

No added

COST

labor

% post

% post

[City, State]

[City, State]

ables?

5

FSC

sealants, paints,

urea-

con-

indus-

Certi-

coatings]

+ equip.]

[note %]

formalde-

sumer 1

trial 2

fied? 6

hyde?

1. CF-AS CJP Foam

Hilti

NK

NK

Belgium

NK

No

N/A

N/A

0.12 g/l

2. CF 812 W&D Foam

Hilti

NK

NK

Estonia

NK

No

N/A

N/A

2.4 g/l

3. CF 116 Filler Foam

Hilti

NK

NK

Germany

NK

No

N/A

N/A

2.1 g/l

4.

5.

6.

7.

NK = Not Known N/A = Not Applicable

NOTES / DEFINITIONS:

1.Post-Consumer Recycled Content: Portion of material or product derived from discarded consumer waste that has been recovered for use as a raw material [e.g., plastic bottles, newspaper]

2.Post-Industrial Recycled Content: Portion of material or product derived from recovered industrial and mfg. materials that are diverted from municipal solid waste for use in a different mfg. process, prior to use by a consumer [e.g., fly-ash in concrete or synthetic gypsum board, both of which are by-products of coal-burning power plants]. Spills and scraps from the original manufacturing process that are combined with other constituents after a minimal amount of reprocessing for use in further production of the same product do not qualify.

3.Manufactured: Final assembly of components into building product that is furnished and installed by trades [e.g., if the hardware comes from Dallas, TX, the lumber from Keene, NH, and the joist is assembled in Kent, WA; then the location of final assembly is Kent, WA]. www.gpsvisualizer.com/calculators can be used to calculate straight-line distance between project site / New York, NY and location of manufacture and raw material source. Note: location noted on material data sheets is often corporate location; need manufacturer to verify actual manufacture location.

4.Raw Materials: Virgin or recovered resources from which the product’s components are made [i.e., before processing or manufacturing].

5.Rapidly Renewable: Materials and products made from raw materials that are harvested within a 10-year cycle [e.g., bamboo, cork, linoleum, fast-growing poplar, wheatboard, wool carpet].

6.FSC Certified: Wood-based products that are certified by the Forest Stewardship Council and carry a Chain-of-Custody certificate number from the vendor or manufacturer.

7.VOC Content: The quantity of volatile organic compounds contained in products such as adhesives, sealants and architectural coatings. VOC content is to be reported in grams/liter or lbs/gallon, less water and any exempt compounds/solvents.

CONTRACTOR CERTIFICATION:

I, ________________________________________ a duly authorized representative of______________________________________________ hereby certify that the information contained herein

accurately represents the listed “green building” characteristics of the materials to be provided by our company as components of the building construction. Furthermore, I understand that any change in such “green building” material characteristics during the purchasing and/or installation period will require prior written approval from the Construction Manager and Owner.

SIGNATURE OF AUTHORIZED REPRESENTATIVE: _____________________________________________

DATE: ______________________