S 3303 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY.OF CUPERTINO BUILDING-ELECTRICAL fE TT NO
BUILDING DIVISION APPIACATION/PERMIT PLUMRwG-MECHANIC\L 3303
BUILDING PROJECT IDF.N'I'IFIC I'ION
BUILDING ADDRESS: /i IV ll ) 7 SANITARY PPLICAr10N SUBMI'PPAL DATE
o v c7 (�/ 15001-
OWNER NAME: P ONE: CONTRACTT OR'S NAME: hIC NO:
/ NIC CON'rROI.#
MdCI '/. GINEER: LIC NO, ADDRISS: ❑ '�.
CON'A P: PHONIC, � " BUILDING PERMITINFO
_ 7 p ❑ Consultant Fees Paid by Applicant(Initial) BLLDDDGG/ ELECT PLUMB MUCH
hICENSED IJTRA OR'S DECLARATION Q.rIY. FLECTRICPIERMIT 1 FEE f LJ CI
1 hcrchy affair that I ant licensed under provisions of Chapter 9(commencing _ t ' r . t...• ., JOB DESCRIPTION
w�Gwith$cdian 9DNl)nl'ITviri 3aClhc Baa,inesxund Pro 'inn,Cn Is,and my Incense Ls _ PBIiMI'f ISSIJANCII �� RF
FLL•LLF nfullforce J I DWI. ❑KI'ICIIIEN I21iMOOI31.
aUU LicenClc.N CIiS-RCSIUIiNa'IAL ❑ADDITION El PLUMBING RF-['IPF.
F LL Dum Cnmrae a
ARCHITECT'SDIi IA'I'10 ❑MULa'I-UNIT []STRUCTURAL
art,7h I'AN ELS MODII'ICA'I'ION
2 O H Z I undeca:aid my plans,feel he used as public resounds
OZ`3"p UP'10200 AMPS ❑INTERIOR 11 CHIMNEY REPAIR
�F Lm�W Licensed l'ndc„ionel 201-IOfI(IAMI'S IAIPROVEMEN'1' 0SWIMMING POOLS
OWNER-r.cra 13Rutthe DECLARATION OVER 11H0AMPS ❑B/GlI REMODIURI31'AIR ❑DIiMOIATIDN
m¢ 1 hereny antra,dtw 1 inn excnnpl rr,nn me cmnaonnFs license haw for me
6010 F1 folhwvingreavorl(Senion 7031.5.Bteinesited Pmferslnns Ctale:Any airy or county SIGNS ELECT RACAL ❑QTHIiR
41 a LL h which require.,a permit to ennxnnn,cher,iniju ,denadivh,OF ocl ur any struc0uc
prior to it,issuance,also require,the inflicter for such pemriuo file a signed anteater, SPECIAL CIRCUIT IMISC_
�k E, mathcis u License Law WhitlerY
fwmnnencingwim$cctinn 9fNs))nfpivieiun3ofine Boniness and Prnfaaninns Caalynr 'TEAIP.METER OR POLE[NST 'R IAA•
e 60 C�C that he is cxempl therefrom and the basis for the alleged excmptinn,Any violation or EW BLDG/AUDITION ❑DEMOLITION
To Seelion]IOI 5 by any updicum for ap,odssubjea,her,licanto,a civil penalty of POWER DEVICES 13NANT ❑FWD SERVICE
�EV' not Anon than lire hundred dollars(3500). PItGVE EMP
d ❑ L as owner nfthe popeny,or...yemployee,wit[,wages it,lncir,ol,nnnpenr:ninn, S MMIN0 POLL ELECTRIC
will do the work,and the structure is not intended oroirced for ale Sec.]OW.Business HER
m and Profmslons Code'llre Contractor's License Law does not apply m all owner a1 lJl'LfSIS-SWITCH[:$-FIXTURES
proNny who builds or iurprnves thereon,and who due,such work himself lir through
his own employees,po vldeal In,such imnmvemmico are N ES UN IAL HLEC-cR SQ
,ala lL however.the huilAing or in,pnrvemhm i,said wimin one year nfeonrpletinn,the SQ.17I.FI.001RAREA $ISQ.IT.
w er-huilder will have the burden of paving that he did not build or improve fn pur. cj
;;nx� 3;?,S-ri y.
1,as owner of the prnpeny,ant exclusively contacting with licensed contractors In TUFA
condoic,theproject(S70oCC Bo sine,andP [ode)I'tic Cod nor .L .. - r - -
11
erase L d t pplyt fp pent h heads or mpbseslhanc J QTY, PLIIMBING.IERMI'I'' FEE ' U may/ qg
wh c..Low.krsuchp Jela wimvn,ta ma(s)liu reed pursuant t,me Cnnruu<'s T 2255 77"• ``77 7-
Licenm Law.
E)lam exempt under$e<. .B h l'C for this ruasnn PERMIT ISSUANCE r
Owner Date AI:1 HE-DRAIN A VENO-WATER TEA) VALUA!T^ION/)
WORKER'S COMPENSATION DECLA KATI ON BACK FLOW PROTECr.DEVICE ' �, ' I O v �/
1 nerehy nRrm under Nr a ty of perjury one of the following deeltast o e:
❑Ihavc and will meinmin aCenillcaleul Consenno sulLlnsure lbr Workcrx Cumpcn- DRAINS-FLOOR.ROOF,ARIA,GOND' lultlli5 T CONSTRUCTION
xvtian,as pmvideA for by Seainn 3900 of the Lnhm Code,for the perfommoce of the
work for which this pemri,is issued. FIX'RJIt ES-PER TRAP
❑ I nave and will mai nlaio Wurkce,Cmnpensalion Innmmmce,it,retained by Section !�
3700calnCLalor Cosi foul if...becefnc�xrolkhor I(this ti,koned GAS-PA.SYS'1'13M-1 INC. GOT'J.,S
fc P<nnt IIQC.GROUP APN
MYW... ompersatinn I ' ll a hru c:
Carl GAS-13A.SYS'1'13M(lVER4(i?A)
C13RT1 F 1 1(jIV T ANCIPORKEBS'
N- Tt GREA51%INUUS'r NL WAS'1"E IN'I'ERCIiI'TOIt
}y,'/���1r �/S�r/�U�(/aJ.tANCE a//��/� BUILDING DIVISION
:I!S
(''his,ea nnaj'K9IDMor'Mfor, 1, illstismed(Lshall GRE SI S'API'1'ANY-STONM EA.211111TI1 - - ---
nlusa PLAN�f IQ C ^j.0
Icenif he fun
not empinyany..t.on men,ownn, ,,as a Leona subjcel m ane Waken"Compen- ENERGYF-- L(�,
O 2. sntion Lawuof Cnlifomia,Dole WATER HPA'IBR W/VCN'OBI.I!CTR
Q Applicant GRADING IBi9
,t, NOHCE TO APPI,ICAN-E If,eller making this Cvr ificale of Exemption,you should WATER SYSTEM/TREAT
ING
F" 5: beecme.subjea to the Workers CoraNdelitn provisions of the Latour Coda you mail SOILS FEB
Uj forthwith comply with such fb vi,ioa,, his Permit shall he dcnned revoked. WATIIR SERVICE
p, A
CON$'fRl1CTION LENDING AOIiNCY NEW RESIDENTIALPLM). SQ.FC PAID
U O hate Rucei 1#
1 hemhy affirm Ih:n there is a enrnwnion lending agency for the I,crhmnunee of Q P
the woA fur which ml I i,issued(See.30'x9.Clv.CJ e
p rnu
LenJere Nannc vaqTOTAL:
OW4Lenders Adarl TQ1'AI.I BUILDING FE
F-t y 1 artily thw luau read this nfplicoliun and saint tum Ane ulnae infnrnavon is _
VN correct Iagree¢a comPlY with lilt day and ammy ordinances aha stole law,relmmga QTY. MECHANICAL PERMIT FEE
Z building ennstmcfon.and hereby authorize repo,entntiveu ofthis city to enter upon the SEISM[
obrve-mentioned property for inspection pu,),c,. 1'fiRMAT ISSUANCE C +�
(We)ngrce m save,indemnify and keep hvmfle. he City ul Cupertino against `� ELECT �( �j-
linnili' judgments,costs and expemeswhichnmyin anywayvicemeaguin,t,.id City ALTERORADDTOMECH.
inc enceofineganlin'ta nniepennil. PLO, rIEE (O
AP .C T UNDERSTANDS ')WILT.COMPLY WITH Al.NON DINT AIR HANDLING UNIT GO 10,000 CFM) ('
1RCI RI3GULA `f.0
MT:C [CAL PSE 3, T
AIRIIANIILING UNITIOVER 10,100C12M1 CONST CfAON TAX ynle-�' Ellis
islificilu p 'Daft I?XIIAUSTHOOD(WIDUCT) HOUSIN MITIGATION PHE
HAZARDOUS MATERIALS DISCLOSURE
Will meapplicant mfature nuJdingrccapanl,torcorhandle haxmdous mmcri:d 1117A'IING UNI'I'(TO I00,00)BTL)
ens
defined by the Cupertino Municipal Col ,Chtpmr 9.12,and the Realm and Safety L IT
Ctde.Secatur 25SCEP! 1[BEA'PINC,UNI P OVER 110.00)ATTAR t
(]}cv VENTILAMONFAN(SING1.13RFSID) PAiD
l Dae - Neaipl s
Will the applicant or luture building occupant use equipment or devices which BOALIiR-COMP pHP OR IIs1,gNl B'lll)
mit hnmbkub,air cotnaminants as defined by the[lay Arca Air Quality Management
District? BOILER-COMP(OVER I00,000 BTU)
❑Vas
1 havei- k— 'J'a
the hudnus mrivlx rnp:ircmnns nnnder Chapmr 495 nl the QJi- - AIR CONDITIONER
, ISSUANCE DATE
fnmis lieahhadSections 25505,25533 and 255 4.1 un mind that if the NEW RESIDP AL MECIL SQ,FI',
M1uilding � ve, fart is my mpnrei t' On verb 1/7
nt her Iain s historic Gtl-u n m u I enpewy.
Dw r m Du1c 'IOTA[- ISSUED BY:
OFFICE
SGEOGEOTECHNICAL AND ENVIRONMENTAL CONSULTANTS
I N C O R P O R A T E D MATERIALS TESTING
Proj ect No.
4136.4.050.01
June 11, 1999
Mr. Pat Burke
The O'Brien Group
2001 Winward Way, Suite 206
San Mateo, CA 94404-2473
Subejct: Lot 4-9, Tract- Oak Valley)
10799 Juniper Court
Cupertino, California
SEISMIC FRAME INSPECTIONS
Dear Mr. Burke:
With your authorization, ENGEO Incorporated performed special inspections related to the seismic
frame installation at the subject property location in Oak Valley in Cupertino, California. This
report is submitted in accordance with Chapter 17 of the Uniform Building Code.
Observation services was provided using the approved plans for the following:
• Shop welding of the seismic frames.
• Field welding of the seismic frame moment connections.
• Field welding of the framing straps.
• Grouting of the base plates.
To the best of our knowledge and based on our observations, the work requiring special inspection
is in conformance with the approved plans, field recommendations of the Structural Engineer, and
the applicable workmanship provisions of the Uniform Building Code...
We make no representation as to the accuracy of dimensions, calculations or any portion of the
design for this project.
If you have any question or comment, please do not hesitate to contact our office.
Very truly yours,
r ,
ENGEO ORPOR D Reviewed by: Q�pFESS10Hq�
EL14ye
Robert X oakimson Uri Eliahu r No. 39522
* Exp fa-31-1 7a
rxj/ce:seismic Jl CIVI1- �
• cc: 1 —City of Cupertino qlf OF CM.���
1 —The O'Brien Group, Mr. Gerry Ploof
2401 Crow Canyon Road •Suite 200•San Ramon,CA 94583-1545 • (925)838-1600•Fax(925)838-7425
E-mail engstaff®engeo.com 0 www.engeo.com
SEISMIC FRAME INSPECTIONS
Tract: Oak Valley
Sequence Number: 4
Lot Number: 4-9
Street Address: 10799 Juniper Court
Shop Welding
Welding inspection in the field
Field Frame Welding
Field Strap Welding
Base Plate Grout
Comply with the approved plans: Yes ® No ❑
Completion Date: June 11, 1999
MAR. 9.1999 1t211PN BRAN iS;NGAS FOULK NO.519 P,22
Brian Kailas Faulk
Engineers • Surveyors • Planners
March 9, 1999
960069.50
Chuck Scitoen�ierpr
O'Brian Group
2001 Winward Way,Suite 20C
San Mateo,CA 94404
Subject: Oak Valley—Foundation Verifegr1lon
Dear Chuck,
On March 9, 1999 we perforsiripci it field survey of die location of the foundation forms for the buildings
being construciud on Lot 4.09 of the Oak Valley protect In Cupertino.
The results of(list survey clearly show that the location of the foundation forms are consistent and in
eonfomtance with the design location of the buildings,as said locations are shown on the plans prepared by
our Irm.
This letter is intended to provide you with the verification of those units per our survey. If there arc auy
other questions concerning that location,please do not hesitate.to call.
Sincerely,
cr;,iD lkNO SG$
G
-
armLC•Y A.K60
IAN KeeZ OU14 EXP.3/31/02
Bradley A. 6ilbor.L.S.G141 �
protect Manager up No.6!41 �
Survey Department OF CPLAF���
540 Price Avenue Redwood City.CA 94003 . (860)462-0300 • FAX(6501482-0399
COnsu/ting Engineers and Scientists DATE tic
L <u/ •�c
425 ROLAND WAY PROJECT
OAKLAND, CA 94621 0'a ZL <:' r ,.-,<: . r•,i �"
(510) 568-4001 LOCATION
J
r /I I / �� �C'oT//vJ l.✓ '
�l.O / I I // /lP J s CONTRACTOR/ 1716
WNER .• .
` c
AUr �J.✓JS. 1 6
CSC/
Date i / / 6-U r WEATHER TEMP.
/ °at M
oat PM
Hours Charged To Project 7 Nuclear Density Tests -eL9FIT AT - -
Field Task Number Concrete Cylinders.-fcl
jon ?69 —`�r{Av iS J o j
THE FOLLOWING WAS NOTED: /
T
i7 l' i 'c'.'
AT 7 { Ti,� P of/ 7�a/5 1/IS/ T' / J'✓ 9 5 '4,11f- eAJdlcclU / i75
Zb
LL/r n.' (,DNC✓°'C� CC. 1111
LA
- s- - 'Ore'!IV,
{.: / /r.,4 A i C'! q✓,.C,9 ✓ �/l yif iN
G( /
�i l �, vv l�ti'� .� ✓R I; F/� N-J .5 ��� .:7 �iNlvl9( Td' �.n1iiNY
v.. -
o
f
i Sr ✓ o4fc N �sr�/ ve-L"ry ve. ..�1 • dc✓eFa F ,/
n,vctl f ..,v !, e / >4 ✓LI
I
cos TO �A T - c /?. , AJ �� �n�
SIGNED
1'� rLULi% Nu.519 P.2/2
Brian KanW Faulk
Engineers • Suryeyart , Planners
March 9, 1999
960069.50
Chuck Schoenyerger
O'Brien Oroup
2001 Winward Way, Suits 200
San Mateo,CA 94404
Subject! Oak Valley—Foundatlon VerlOcallon
Dear Chuck,
On March 9, 1999 we performed a field survey of the (acarian of the foundation forms for the buildings
being constructed on Loi�of•the Oak Valley project In Cupertino.
The results of that survey clearly show that the locadon of the foundtuion forms aro Mislstent and in
eonfomtnncC with the design location of the buildings,as said locations arc shown on the plana prepared by
our 11ml
This letter is intended to provlde you with the veriflcation Of Chose unite per our survey. If Ihore arc any
Other questions concerning that location,please do not hesitate.to call.
Sincerely,
_ 1��rv0 FANO SG�`�p
IAN K BRADLEY h.BtLRO p0
OU61 �.
Bradley A. Bilbo P.L,9.6I41 UP.3/31/02
Project Manager No. 6141 �r
Survey Department OF CAItFO��
540 Prim Avenue • Redwood City,CA ill • I8810 4824300 • FAX i8t 01 482-8399
w 4
Brian Kangas Faulk
Engineers • Surveyors • Planners
•
March 9, 1999
960069-50
Chuck Schoenberger
O'Brien Group
2001 Winward Way, Suite 200
San Mateo, CA 94404
Subject: Oak Valley—Foundation Verification
Dear Chuck,
On March 9, 1999 we performed a field survey of the location of the foundation forms for the buildings
being constructed on Lot 4-09 of the Oak Valley project in Cupertino.
The results of that survey clearly show that the location of the foundation forms are consistent and in
conformance with the design location of the buildings, as said locations are shown on the plans prepared by
our firm.
This letter is intended to provide you with the verification of those units per our survey. If there are any
other questions concerning that location,please do not hesitate to call.
• Sincerely,
IAND S�9
eOULK =S 6
BRADLEYA.BILBOIAN �c EXR 3/31/02
Bradley A. Bilbo P.L.S. 6141 Q
Project Manager /] No. 6141
Survey Department 9lc OF CAO'
•
540 Price Avenue Redwood City,CA 94063 1650 4826300 FAX(650)482.6399
•
0 0?BRIEN
,PGROUP
Patrick Burke
From: Jim Rlpley(SMTP:ripleydg®pacbell.not]
Sent: Monday, March 08, 1999 2:26 AM
To: PAT BURKE
Subject: OAK VALLEY
Pat Burke
Oak Valley
Cupertino, e b?C
Reference: Linear parkway planting, v
Pat,
All plantings within the linear park are consistent with the landscape
construction documents prepared by this office and reviewed by the City
on March 1998 and conform with the preliminary approval douments,
Jams. Ripley
Ripley Design Group, Inc,
HHAL PLAWNG ON OFF
®ATE �0y/99
,INWARD WAY,SUITE 200.SAN MATEO,CALIFORNIA 94404.2473 TF.LFFIIONF.(6501377.0300 FACSIMILE(610)3493442
• G•vl�•d Mvrh 1, 1996 "
ENGINEERING WEST INC.
OBSERVATION CHART
OAK VALLEY DEVELOPMENT CUPERTINO, CA.
• PAT BURKE 8TRAUSB BROS. PAGE 1 OF 3
680 217-0076 408 2S7-1923 DATE: 8-29.9
THIS CHART INDICATES THE DATES AT WHICH EACH COMPONENT OF:EACH BUILDING WAS
OBSERVED AND FOUND IN SUBSTANTIAL CONFORMANCE WITH THE IMAWINGS.
LEGEND
N.O. CONSTRUCTION NOT COMPLETELY OBSERVED
• • CORRECTIONS REO'D. UST GIVEN TO CONTRACTOR.
FDN. STEEL REINFORCING,HOLDOWN ANCI4OR BOLT OBSERVATION
1 ST FLOOR UNDERFLOOR FRAMING OBSERVATION
ROOF PLY. PLYWOOD NAILING OBSERVATION
EXTERIOR PLY. PLYWOOD NAILING,HARDWARE OBSERVATION
BASIC FRMG. ■ GENERAL FRAMING AND HARDWARE OBSERVATION
I of Plan PTI n. A 'S latnoor � xl eac
4 04/12/99 4/99 D5/24/99
4 8 1 7C 03/10199 04/14re9 0824/99 0624/99 07/01199
4 9 SC 3/BONUS 03/10199 04/14/99 07/09/09 07/09/99 0729199
4 10 2D 3 03/01/99 --al-02j-9 0720/99 07/14/99 0729/99
4 11 38 03/01199 04102'99 07/01/99 06/30/99 07/16/99
4 12 48 311/13/98 12/10198 0121199 0121/99 0125/88
4 13 6C 2 0928/98 10/09.98 11/00/98 11/13/98 12/15/98
4 13 8C ADDITION 6 1 02/09,99 02/09/99 02/09/99 02/08!99
4 14 2A 2 02/02/99 1 03/0199 05/19/99 0581199 06/04/99
4 15 5D 2 02102199 1 03/06.99 0527/99 06/09/99 06/09199
4 17 1 2C 03/01/99 1 03130.99 08/17/99 08/30/89 07/06/99
4 18 I 6E 2/BONUS 12/14198 1224198 03/08/99 03/08199 04/12/99
4 20 48 3/BONUS 1282/88 04/14/99 03/18199 0382/89 04/14/98
4 21 28 2 03/19!99 04/14199 0727/98 0787/99 08110/99
• 4 22 SA 2/BONUS 03/19/99 04/14/99 0780/99 0783/99 08/10199
4 23 3A 1 3 01/12/99 02/18/99 05113199 OS-07-99 08/01199
4 24 6D I 3190NUS 01/12199 02/17/99 0543-99 04-30-99 05/17/89
4 25 SC 1 —3 -72—/23198 02/15199 04/02/99 04/05/99 05/14199
4 26 2D 1 2 01/08/99 02/12199 05/10/99 1 0428/99 05111199
4 27 4C 1 3 01/08/99 02/05/98 04/14/99 04112/99 05 07-99
4 288B 3BONUS 12/14/98 01104!99 03/03/99 03/03/99 03/30/99
4 29 7A 2 11/13/98 12/10/98 02/10199 02/10/99 03/03/99
4 30 3C 3 11/13/98 12/10/96 02103199 02/01/99 03/11199
4 31 58 3BONUS 02712/99 03118199 06/03/99 08/09/99 06117199
4 32 28 3 1 02/12199 03/10799 08111199 08!17/99 08/30!99
NOTES:
(1)•LOT 13 PLAN 8C PON. (OFFICE OPTION); CORRECTIONS NOT OBSERVED.
• 10'd OLGI 963 904 -LS3M SNIU33NION3 dL£=60 66-0£-5ny
•
T
Consulting Engineers and Scientists 3 1/ - 8'!0DATE JOB Na
425 ROLAND WAY PROJECT
OAKLAND, CA 94621 1r,
• (510) 568-4001 LOCATION
r h ^u
To CON OWNER
Date��nfC.l'\ II j��� IrSG1 C, 1/ WEATHER TEMP. 6 'at
AM
/ en G,'at PM
.s CPRESENT AT 617E
-
Flourharged To Project Nuclear Density Tests 1
Field Task Number Tr-I 1 Concrete Cylinders
THE FOLLOWING WAS NOTED:
t�>, SVC CA '- ' f[4-c 16' L-rr( C— i CO,'lrr[ (-C 2TPVYVA-1I-
r
G l r 0 SMi . -1 12) c H" r a D,e Sr, d tai o
In f r1 ,r-rU� r en-4 rA ' -r[, I c 1 e) /'3 �c/ rcl� v cy o nr T a r'
l2CO74 5�a � dol' )^C,1- N 10 a , it7 Slern r.LI/ 1-rx,h �,rS
U U
Fr✓ - 1 ��-5 c >4 - 8 �, ,,d C z rowk r.) L-0
Rn IG tienPSlr r
Sam Gln nF r� ,r Y-e I—[' j1 1111 Pr1 � � C_r.,i[+ r[Icf_ L
it
AA G{ 721 , -P %—I I A rt / `� Z �IkKL (t,rl�� CrinrZC. lO
`^
COPIES TO O C L� oD D D'O cT
SIGNED
CLIENT.
•
s zz e:s, e.6 s e
m § ; i # § § S § § \ 2) ) §
k w
§ k 2 > 2
c ) % m § m (\
§ z £ gA
7 `
J°
� � ([ � � . .
) cl § k D 2 (
• , ■ @ _ e ,
(D �
P.CL
Off
m o § / $
K a
CL
} Z
2 U a � �
I �
� 4
� �
.INSTALLATION CERTIFICATE (page 1 of 4) — CF-6R
10 re's -Permit Number Add
An installation certificate is required to be posted at the building site or made available for all appropriate inspections. (The
information provided on this form is required;however,use of this form to provide the information is optional.) After
completion of final inspection,a copy must be provided to the building department(upon request)and the building owner at
occupancy,per Section 10-103(b).
-HVAC SYSTEMS:
`Heating Equipment
Equip. 0 of Efficiency Duct Duct or Heating Heating
Type(pkg. CEC Certified Mrr Name Identical (AFUE,ele.)t Location Piping Load Capacity
heat um and Model Number Systems F-IR value attic etc. R-vstue (Btu/hr) Btulbr
Sr t
ND FriAuil[IE s s'RAya7o-iz
r
Cooling Equipment
Equip. CEC Certified Compressor 0 of Efficiency Duct Cooling Cooling
Type(pkg Unit Mfr Name and Identical (SEER,etc.)t Location Duct Load Capacity
heal um Model Number Systems CF-Iltvalue (attic,etc. R-value (Btu/hr) tu/hr
rN p in�,r _L �Tr.X700 D ,
1. >_reads greater than or equal to.
1, the undersigned, verify that equipment listed above is: 1) is the actual equipment installed,2)equivalent to or more
efficient than that specified in the certificate of compliance(Form CF-IR) submitted for compliance with the Energy
Efficiency Standards for residential buildings, and 3)equipment that meets or exceeds the appropriate requirements for
manufactured devices(from the Appliance Efficiency Regulations or Part 6),where applicable.
•�i �u�iiai_,. h�17-Q�
'Si urf
Signature,Date Installing Subcontractor(Co.Name)
OR General Contractor(Co.Name)OR Owner
NATER HEATING SYSTEMS:
Distribution IfRecir- gof Rated' Tank Efli- External
Heater CEC Certified Mfr Type(Std, culation, Identical Input(kW Volume eieney' Standby' Insulation
Type Name A Model Number Point-of-Use) Control Type Systems or Btulhr) (gallons) (EF,RE) Loss(s/) R-value
2 For small gas storage(rated input of less than or equal to 75,000 BtuAtr),electric resistance and heat pump water beaten,list Energy Factor,
For large gas storage water heaters(rated input of greater than 75,000 Btulhr),list Recovery Efficiency,Standby Loss and Rated Input
For instantaneous gas water beaten,list Recovery Efficiency and Rated Input
Faucets&Shower Heads:
All faucets and showerheads installed are certified to the Commission,pursuant to Title 24,Part 6,Subchapter 2,Section
Ill.
1, the undersigned, verify that equipment listed above my signature: 1) is the actual equipment installed;2) is equivalent
to or more efficient than that specified in the certificate of compliance (Form CF-1 R)submitted for compliance with the
Energy Efficiency Standards for residential buildings;and 3)the equipment meets or exceeds the appropriate requirements
for manufactured devices(from the Appliance Efficiency Regulations or Part 6),where applicable.
Signature, Date Installing Subcontractor(Co.Name)OR
General Contractor(Co.Name)OR Owner
COPY TO: Building Department
Building Owner at Occupancy
I Morrh 1. 1996
•