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12070030
CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10466 S TANTAU AVE CONTRACTOR: BRAHMAJI POTU PERMIT NO: 12070030 OWNER'S NAME: BRAHMAJI POTU 10466 S TANTAU AVE DATE ISSUED: 02/14/2013 OWNER'S PHONE: 4084463255 CUPERTINO, CA 950I4 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL El COMMERCIAL License Class Lic. # NEW 2 STORY HOUSE 3321 SQFT AND ATTACHED GARAGE Contractor Date 479 SQFT- SANITARY IS SUNNYVALE'S JURISDICTION I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain a certificate of consent to self - insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct. 1 agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature_ Date OWNER- BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three declarations: I have and will maintain a Certificate of Consent to self - insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 1 have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If, after making this certificate of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all no o' t source regulations per the Cupertino Municipal Code, Section 9.I8. Signature Date 2 �� Sq. Ft Floor Area: I Valuation: $490000 APN Number: 37509048.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 1 0 DAYS OF PERMIT ISSUANCE OR 180 DAY R Z LAST CALLED INSPE TION. Issued by: Date: RE- ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, l agree to remove all new materials for inspection. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance wit the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. Owner or authorized agent: L t Date: CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Add ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed I CITY OF CUPERTINO BUILDING PERMIT 1 BUILDING ADDRESS: 10466 S TANTAU AVE OWNER'S NAME: BRAHMAJI POTU OWNER'S PHONE: 4084463255 ❑ LICENSED CONTRACTOR'S DECLARATION License Class Lie. # _ S I_ P Contractor Date I hereby affirm t at I am licen n r he provisions of ha ter 9 (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. 1 hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain a certificate of consent to self - insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection pu o es. (We) agree to save indemnify and keep harmless the City of IC gaf st liabilities, judgments, costs, and expenses which may aecru costs ity in consequence of the granting of this permit. Addit' y, the is t understands and will comply with all non -point sources gulations the upcEtin� Municipal Code, Section L 9.18. /� J i _.« I hereby affirm that I am exenf'p t from the Contractor's License Law for one of the following two reasons: 1, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three declarations: I have and will maintain a Certificate of Consent to self - insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 1 have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If, after making this certificate of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. APPLICANT CERTIFICATION 1 certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Date CONTRACTOR: CALIFORNIA HOMES PERMIT NO: 12070030 AND KITCHEN DESIGN 1775 JUNCTION AVE DATE ISSUED: 02/142013 SAN JOSE, CA 95112 PHONE NO: (408) 392 -8200 JOB DESCRIPTION: RESIDENTIAL 11 COMMERCIAL NEW 2 STORY HOUSE 3321 SQFT AND ATTACHED GARAGE 479 SQFT- SANITARY IS SUNNYVALE'S JURISDICTION REVISION # 1 - REVISE SHEARWALL - ISSUED 7/11/2013 Sq. Ft Floor Area: I Valuation: $490000 APN Number: 37509048.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS Q RMIT ISSUANCE OR 180 DAYS F CALLED INSPECTION. Date: / RE- ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, 1 agree to remove all new materials for inspection. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Ch a ter 9.12 and the Health & Safety Code, Section 25532(x) should I stor -tAw Irk"' a hazardous material. Additionally, should I use equipmoA-a devi which emit hazardous air contaminants as defined by the $ay �C era Air My Mknagement District I will maintain compliance witji- a Cupertino ni ' Code, Chapter 9.12 and the Health & Safety C ' ecti , Owner or a orize$agent: Date::TT� CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Address ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional J Lo CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255 GCEWCoNmuunoN TINO (408) 777 -3228 • FAX (408) 777 -3333 • building(ftupertino.org ❑ ADDITION ❑ ALTERATION /TI ❑ REVISION /DEFERRED ORIGINAL PERMIT # PROJECT ADDRESS i . 4-ct, Lk-69 a APN # /� VF e �/ L-) OWNER NAME 1< T l l PHONE 4 4., -3 2 I E-MAIL , STREET ADDRESS CITY, STATE, ZIP FAX CONTACT NAME PHONE E -1 1' ! V3. I Ve • "e�M '% N OT LA, >� 1 o STREET ADDRESS CITY, STATE, ZIP FAX " -,,t cis 9 OWNER ❑ OWNER - BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT RR -T LICENSE NUMBER LICENSE TYPE BUS. LIC # CONIPAa NAME E -MAIL FAX u STREET ADD CITY STATE, ZIP HO — i 2 _ Ccvcvt a CA-cy1 ^ v LICENSE NUMBER BUS. LIC # COMPANY NAME E -MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK EXISTING USE PROPOSED USE CONSTR. TYPE # STORIES - USE TYPE OCC. SQ.FT. VALUATION (S) Y I�NET AREA TGt� AREA AREA AREA 1 R lA -- 1 Ll � � O,o © fl 13 BATHROOM REMODEL AREA N / A- KITCHEN y� y REMODEL AREA 1 -J OTHER 1� REMODEL AREA PORCH ARCEA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA DETACH V3 WTTACH k DWELLING UNITS: IS A SECOND UNIT ❑ YES SECOND STORY rl YES BEING ADDED? W. ADDITION? NO PRE - APPLICATION YES IF YES, PROVIDE COPY OF PLANNING APPL # NO PL G APPROVAL LETTER IS THE BLDG AN ❑ YES EICHLER HOME? RECEIVED BY: ///'''''jjj ///+++ TOTAL VALUATION: RNO 1 J r r'o By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to ilding constructs . I autho ' representatives of Cupertino to enter the above - identified property for inspection purposes. Signature of Applicant/Agent: Date: IC4 t- 2_ SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECK TYPE R0tMNG SUP ❑ OVER THE - COUNTER ff""�(�LDING PLANREVIEW New SFD or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ EXPRESS � _,��---�� Q'-PLA M NG PLAN REVIEW _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure 9- STANDARD ❑ �c WoOmo form if Hazardous Materials are being used as part of this project. ❑ AGE Copy of Planning Approval Letter or Meeting with Planning prior to 13 MAJOR �, /'n�EPr LT 6AN1TpRY SEWER DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH Bldg App 2011.doc revised 06/21/11 W-0 CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION OCCUPANCY TYPE: ADDRESS: 10466 s. tantau ave. DATE: 07/05/2012 REVIEWED BY: bobs. PC FEE ID APN: BP FEE ID `VALUATION: 1$490,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: New Construction PRIMARY SFD or Duplex USE: 2nd Unit? 0 Yes •' No PENTAMATION 1 R3SFD i I PERMIT TYPE: WORK sfd new livinq space 3274 s.f. , gara a 479 s.f. porch 47 s.f. SCOPE OCCUPANCY TYPE: TYPE OF CONSTR. FLR AREA s.f. PC FEES PC FEE ID BP FEES BP FEE ID R -3 (Custom) II- B,111- B,IV,V -B 3,800 $3,005.08 IR3PLNCK $3,155.77 IR3INSP $0.00 PME Plan Check: $0.00 Permit Fee: $3,155.77 Suppl. Insp. Fee-0 Reg. Q OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: TOTALS: 3,800 $3,005.08 $3,155.77 1 NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School hictrirt otr_ ) Thace fevc are hated an the nreliminary infnrmatinn available and are Only an estimate. Contact the Dent for addn'l info. FEE ITEMS (Fee Resolution 11 -053 Eff 7/1.11) FEE QTY /FEE MISC ITEMS Plan Check Fee: $3,005.08 Select a Misc Bldg /Structure or Element of a Building Suppl. PC Fee: Q Reg. OT 0,0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $3,155.77 Suppl. Insp. Fee-0 Reg. Q OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Tax: IBCONSTAXR 1 # new units $595.41 G Work Without Permit? 0 Yes (j) No $0.00 Advanced Plannin Pee: IPLLONGR $494.00 Select a Non - Residential Building or Structure G Strong Motion Fee: IBSEISMICR $49.00 Select an Administrative Item 1314 Stds Commission Fee: IBCBSC $20.00 SUBTOTALS: $7,319.26 $0.00 TOTAL FEE: $7,319.26 Revised: 07/01/2012 CUPERTINO ❑ NEW CONSTRUCTION CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255,,--'-`*` 5014 - 325 -`*` (408) 777 -3228 • FAX (408) 777 -3333 • building(c)c r 1-ro.orq ❑ ADDITION ❑ ALTERATION/TI .❑ ' REVISION / DEFERRED ORIGINAL PERMIT # I, Zo7 0030 PROJEC[ ADDRESS � � � APN � � OWNER NAME PHONE t/d Lilt 32 �J� E -MAII (F n U L STREET ADDRESS CITY, STATE, ZIP FAX CONTACT NAME ` _ C PHO \ © (- E -MAIL S STREET ADDRESS ( CITY, STATE, ZIP FAX O ^ J ) �� J 1 c7 ❑ OWNER ❑ OWNER - BUILDER ❑ OWNER AGENT CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS. L1C # i I1�Or, COMPANY NAME C E -MAII. FAX D g- rj zO( c, U G -e STREET ADDRESS CITY, STATE, ZIP _ Shr� -c� - S (� �2- PHONE C --to \� IOU ARCHTTECT/ENGINEERNAME LICENSE NUMBER BUS. LIC # COMPANY NAME E -MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK J EXISTING USE PROPOSED USE CONSTR TYPE STORIES USE TYPE OCC. SQ.FT. VALUATION ($) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NETAREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: LJ DETACH ❑ ATTACH k DWELLING UNITS: IS A SECOND UNIT ❑ YES SECOND STORY ❑YES BEING ADDED? []NO ADDITION? ❑NO PRE - APPLICATION ❑ TES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YES j�C B'] .: n _ ".; TOTAL VALUATION: PLANNINGAPPL# ❑NO PLANNING APPROVAL LETTER EICHLERHOME? ❑NO By my signature below, I certify to each of the following: I am the prope Or fu e roperty OIAmer's behalf. I have read this application and the information I have provided is correct. I have e cription of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building construe ' e�' of Cupertino enter the above - identified property for inspection purposes. Signature of Applicant/Aeent: Date: SUPPLE MEN RIN1A N REQUIRED °`' `PLAIVCHECKTYPE ., x "> r ROIITTrG'SLIP New SFD or Multifamily dwellings: Apply for olition permit for fr k - ❑ VER THE COIPvTER BUILDLIGPLANREVIEw existing building(s). Demolition permit is requ' prior to issuance of building R permit for new building. ❑ EXPRESS 3 ❑ PLANN'INGPLnNRREEVIEw Commercial Bldes: Provide a completed Hazardous Materials Disclosure Cl sTAnDnRD Y ❑ puBLlcwoRxs k form if any Hazardous Materials are being used as part of this project. ,mss } _. y'^ h X 1 4 LARGE'"f+ � �WI;�� �j jY ❑ yFiREDEP'I`���" ���°��' ��� 6 Copy of Planning Approval Letter or Meeting with Planning prior to 4� s= _ submittal of Building Permit application. ntiAaox r ' ❑ SAI�TTARYSEwERj DISTRIC AP ❑ v _EN�7RO1VhIENT'.4Z HEALTH s' .. BldgApp_2011.doc revised 06121111 rm-7 CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION 1AADDRESS: 21510466 s tantau ave DATE: 08/07/2013 REVIEWED BY: MENDEZ MISC ITEMS APN: BP #: *VALUATION: Iso "PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex USE: hrs PENTAMATION 1GENRES PERMIT TYPE: WORK revision #2- remove upstairs bathroom and install guardrail SCOPE NOTE. This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School Metrirt otr ) Thoco fooe aro hocod nn tho nroliminom infnrmotinn ovoilahlo and aro only an ostimato_ Contort tho Dont fnr oddn'l.infa_ FEE ITEMS (Fee Resolution 11 -053 Eff. 7/1112) FEE QTY /FEE MISC ITEMS Plan Check Fee: Hourly Only? () Yes (E) No $0.00 17 hours Plan Check, Hourly $139.00 /STPLNCK Suppl. PC Fee: Q Reg. Q OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee.0 Reg. Q OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 0 Work Without Permit? Yes Q No $0.00 Advanced Planning Fee: $0.00 Select a Non - Residential Building or Structure Q Strong; Motion Fee: $0.00 Select an Administrative Item Bldg Stds Commission Fee: $0.00 SUBTOTALS.'' $0.00 $139.00 TOTAL FEE: $139.00 Revised: 07/01/2013 FEW CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION 0 r ,i7Vf 1,h r1, 1 V, 1'/ .i _', t NOTF,: This estimate does not include fees due to other Denartmentc (i.e. Planninn. Puhlic Works. Fire. Sanitary Sewer District. School District etr_►_ Thew fees are haled an the nreliminary information availahle and are nnly an estimate Contact the Dent for addn'1 info. FEE ITEMS (Fee Resolution 11 -053 Eff 71I!12) ADDRESS: 10466 S TANTAU AVE DATE: 07/11/2013 REVIEWED BY: MELISSA MISC ITEMS APN: BP #: 'VALUATION: Iso %PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex USE: 0.0 PENTAMATION 1GENRES PERMIT TYPE: woRK REVISION # 1 - REVISE SHEARWALL SCOPE 0 r ,i7Vf 1,h r1, 1 V, 1'/ .i _', t NOTF,: This estimate does not include fees due to other Denartmentc (i.e. Planninn. Puhlic Works. Fire. Sanitary Sewer District. School District etr_►_ Thew fees are haled an the nreliminary information availahle and are nnly an estimate Contact the Dent for addn'1 info. FEE ITEMS (Fee Resolution 11 -053 Eff 71I!12) FEE QTY /FEE MISC ITEMS Plan Check Fee: Hourly Only? Q Yes 0 No $0.00 1 1 hours Plan Check, Hourly $139.00 ISTPLNCK Suppl. PC Fee: 0 Reg. 0 OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee-0 Reg. 0 OT 1-0-.0-1 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 <Jt2.i ft'Ut'f t4Y: 16'A. 0 Work Without Permit? Yes 0 No $0.00 Advanced Plannin& Fee: $0.00 Select a Non - Residential Building or Structure 0 A r<i, cz i7t�r, r.Intitt ';, �,� rut, _s. Stroniz Motion Fee: $0.00 Select an Administrative Item Bld£*. Stds Commission Fee: $0.00 SUBTOTALS:" $0.00 $139.00 ' TOTAL FEE: $139.00 Revised: 07/01/2013 I CITY OF CUPERTINO BUILDING PERMIT I BUILDING ADDRESS: 10466 S TANTAU AVE OWNER'S NAME: BRAHMAJI POTU OWNER'S PHONE: 4084463255 LICENSED CONTRACTOR'S DECLARATION License Class —?< Lic. #�_ - Contractor'n I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain a certificate of consent to self - insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 1 have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature 6 :' x0 �S Date ___ -- -iii"' ❑ OWNER- BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 1, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three declarations: I have and will maintain a Certificate of Consent to self - insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If, after making this certificate of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Date CONTRACTOR: CALIFORNIA HOMES AND KITCHEN DESIGN PERMIT NO: 12070030 1775 JUNCTION AVE DATE ISSUED: 02/14/2013 SAN JOSE, CA 95112 PHONE NO: (408) 392 -8200 JOB DESCRIPTION: RESIDENTIAL COMMERCIAL NEW 2 STORY HOUSE 3321 SQFT AND ATTACHED GARAGE 479 SQFT- SANITARY IS SUNNYVALE'S JURISDICTION REVISION #3- TRUSS CALCS- ISSD 10/4/2013 Sq. Ft Floor Area: I Valuation: $490000 APN Number: 37509048.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN IN DAYS OF PERMIT ISSUANCE OR 180 DAY M LAST CALLED INSPECTION. Issued by: Date: _/ RE- ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. Signature of Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. Owner or authorized agent: K Date:_1 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Address ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10466 S TANTAU AVE CONTRACTOR: CAI.IFORNIA I IOMLS AND PERMIT NO: 12070030 KhhCIIF.N DI?SIGN OWN'ER'S NAME: BRAHMA,II POTU 1775 JUNCTION AVE DATE ISSUED: 02/14/2013 OWNER'S PHONE: 4084463255 SAN JOSE, CA 95112 PnoNE NO: (408) 392 -8200 LICENSED CONTRACTOR'S DECLARATION BLILDING PERMIT INFO: 13LDG ELECT PLUMB License Class - MECH' RESIDENTIAL COMMERCIAL Contractor hereby affirm t at I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: Nf;W 2 STORY IIOUSF, 3321 SQP "f AND Al'IACI II[D (commencing with Section 7000) of Division 3 of the Business & Professions GARAGE 479 SQI''I'- SANITARY IS SUNNYVALE'S JURISDICTION Code and that my license is in full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain a certificate of consent to self- insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 ofthc Labor Code, for the performance of the work for which this Sq. Ft Floor Area: Valuation: $490000 permit is issued. APPI,ICANT CE12'I'IFICA'1'ION APN Number: 37509048.00 Occupancy Type. I certify that 1 have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City ol'Cu o a" cost liabilities, judgments, PERMIT EXPIRES IF WORK IS NOT STARTED costs, and expenses which may accr ba nst said. r con t sequence of the granting ofthis permit. Additio 1y, the appltk�? erstands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR with all non -point sou rc gulations pe �Ize- ertinno Municipal Code, Section 9 I8 180 DAYS FROM LAST CALLED INSPECTION. Signatu ' Date— ?7� -f /" Issued by: >GtT Date:�'��" /3 r' 1 r ❑ OWNER - BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractor's License Law for one of RE: ROOFS: the following two reasons: All roots shall be inspected prior to any roofing material being installed If a roof is I. as owner of the property, or my employees with wages as their sole compensation, installed without first obtaining an inspection, I agree to remove all new materials Ibr will do the work, and the structure is not intended or offered for sale (Sec.7044, inspection. Business & Professions Code) 1, as owner ofthe property, am exclusively contracting with licensed contractors to Signature of Applicant Date construct the project (Scc.7044, Business & Professions Code). --- - - - - -- 1 hereby affirm under penalty of perjury one of the following three AI., ROOF COVERINGS TO BE CLASS "A" 012 BETTER declarations: I have and will maintain a Certificate of Consent to self- insure for Worker's LIA' /,ARDOUS MATFI2IALS DISCLOSURE Compensation, as provided for by Section 3700 of the Labor Code- for the performance of the work for which this permit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain Worker's Compensation Insurance, as provided for by California Ileafth & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain Section 3700 ofthc Labor Code, for the performance ofthc work for which this compliance with the Cupertino Municipal Code, Chapter 9.12 and the health & Safety Code, Section 25532(a) should 1 store or handle hazardous material. permit is issued. Additionally, should 1 use equipment or devices which emit hazardous air I certify that in the performance of the work for which this permit is issued, I shall contaminants as defined by th - Area Air Quality Management District 1 will not employ any person in any manner so as to become subject to the Worker's maintain compliance e C e.�ino Municipal Code, Chapter 9.12 and the Compensation laws of California. If, after making this certificate ofexemption, I Ilealth & Safetyk-'6 e, Secti s 25505, 25533, and 25534. become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. Ow c IN ,eed e J Date: / J APPLICANT CERTIFICATION CONSTRUCTION LENDING AGLNCI 1 certify that I have read this application and state that the above information is correct. 1 agree to comply with all city and county ordinances and state Taws relating I hereby affirm that there is a constriction lending agency for the perlormancc of tvrrk's to building construction, and hereby authorize representatives of this city to enter for which this permit is issued (Sec. 3097. Civ C.) upon the above mentioned property for inspection purposes. (We) agree to save Lender's Name__ indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the Lender's Address _ granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section ARC'IIITECh'S DECLARATION 9.18. 1 understand my plans shall be used as public records. Signature Date Licensed Professional CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10466 S TANTAU AVE CONTRACTOR: CALIFORNIA HOMES PERMIT NO: 12070030 AND KITCHEN DESIGN OWNER'S NAME: BRAHMAJI POTU 1775 JUNCTION AVE DATE ISSUED: 02/14/2013 OWNER'S PHONE: 4084463255 SAN JOSE, CA 95112 PHONE NO: (408) 392 -8200 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIALE] License Class Lic. to NEW 2 STORY HOUSE 3321 SQFT AND ATTACHED GARAGE Contractor Date 479 SQFT- SANITARY IS SUNNYVALE'S JURISDICTION I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business & Professions revision #2- remove upstairs bathroom and install guardrail -issd Code and that my license is in full force and effect, otc- 8/7/2013 1 hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain a certificate of consent to self - insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the Sq. Ft Flo rea: Valuation: $490000 performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. N 509048.00 Occupancy Type: APPLICANT CERTIFICATION I certify that I have read this application and state that the abo in ormation is PERMIT EXPIRES IF WORK IS NOT STARTED correct. I agree to comply with all city and county ordinances and state laws relating WITHIN 80 DAYS OF PERMIT ISSUANCE OR to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save 180 DA F OM LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the Q/ granting of this permit. Additionally, the applicant understands and will comply Issued by: Date: u Z// with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. RE- ROOFS: Signature Date All roofs shall be inspected prior to any roofing material being installed. if a roof is WTinstalled without first obtaining an inspection, I agree to remove all new materials for inspection. ❑ OWNER- BUILDER DECLARATION Signature of Applicant: Date: I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER I, as owner of the property, or my employees with wages as their sole compensation, wil I do the work, and the structure is not intended or offered for sale (Sec.7044, siness & Professions Code) I, owner of the property, am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project (Sec.7044, Business & Professions Code). 1 have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the eclarations: Health & Safety Code, Section 25532(x) should I store or handle hazardous I have and will maintain a Certificate of Consent to self - insure for Worker's material. Additionally, should I use equipment or devices which emit hazardous Compensation, as provided for by Section 3700 of the Labor Code, for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, S tions 25505, 2M3, a d 25534. 1A Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized agent: a CA Date: permit is issued. ty I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If, after making this certificate of exemption, I CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code, I must 1 hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save ARCHITECT'S DECLARATION indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of is permit. Additionally, the applicant understands and will comply with all no - oint source regulati s r th Cupertino Municipal Co e, S coon Licensed Professional 9.18. Signature Date CUPERTINO 14 L CONTRACTOR / SUBCONTRACTOR LIST Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014 -3255 Telephone: 408-777-3228 Fax: 408-777-3333 JOB ADDRESS: 104 66 S -FAYI -FAv A.Ve PERMIT # 1Z o l o o3 a OWNER'S NAME: ra�% wa�'\ "�'-1 PHONE # o - - & 2 0 0 GENERAL CONTRACTOR: Ca I ;Sto A;A (,f BUSINESS LICENSE # 30yS ADDRESS: 17 7 t- T. w C"�s oM AVe- CITY /ZIPCODE: <,,,A. i^ 0c, a ) /1 7 *Our municipal code requires all businesses working in the city to have a City of Cupertlfio business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Signature Please check applicable subcontractors and complete the following information: Date 1 �of I / lei w e/ntrractor Signature Date SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing N 3 o Lk S Electrical Excavation Fencing Flooring/ Carpeting Linoleum / Wood Lk �- Glass / Glazing t- Heating /' Insulation Landscaping VX S✓ ` �� So� \)T' oL^ Lathing Ceti C-1 M-C4 Masonry C, �( Painting / Wallpaper '� o S Paving Plastering i Plumbing 7D4 �—O\ Roofing A,, �L� Z 9 r1 Z Septic Tank ---------- - -- Sheet Metal Sheet Rock Tile 1 �of I / lei w e/ntrractor Signature Date CUPERTINO CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255 (408) 777 -3228 • FAX (408) 777 -3333 • building(ftupertino.org /26 -7 (,50 U NEW CONSTRUCTION U ADDITION U ALTERAATION / Ti U REV -I i 5N– / DEFERRED ORIGINAL PERMIT # PROJECT ADDRESS 7 it � APN # OWNERNAME /� � /s�Jpf, pdru PHONEC /O$ _L114 6 E -MAIL STREET ADDRESS CITY, STATE, ZIP FAX ICONTACT NAME 40 :2con 1r ve ,� PHONE �._ � E -MAIL I STREET ADDRESS CITY, STATE, ZIP I FAX ❑ OWNER ❑ OWNER - BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS. LIC # COMPANY NAME E -MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME E -MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK �✓ s EXISTING USE PROPOSED USE CONSTR. TYPE # STORIES I USE TYPE OCC. SQ.FT. VALUATION ($) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECKIPORCH AREA GARAGE AREA: DETACH ATTACH # DWELLING UNITS: IS A SECOND UNIT ❑ YES SECOND STORY [3 YES BEING ADDED' []NO ADDITION' []NO PRE - APPLICATION []YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YES„" = TOTAL VALUATION: PLANNING APPL# []NO PLANNING APPROVAL LETTER EICHLER HOME' []NO�� By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to buil ing construcctio . I authorize representatives of Cupertino to enter the above - identified property for inspection purposes. Signature of Applicant/Agent: a 46L a / Date: SUPPLEMENTAL INFORMATION REQUIREDC fi SLIP OVE1t TZiE t11Y fElt G SEiit liliwl( 11"I AN li i 'w- _ New SFD or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building, ,. permit for new building. Q xxiREss,: PL�iVNI+1G1" ? VIEW _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure TANUA f °tl[CiKRizs ; form if any Hazardous Materials are being used as part of this project. Copy of Planning Approval Letter or Meeting with Planning prior to CI aax' fjk submittal of Building Permit application. WIIMM61, © ENVIRONMENTAL' ALIrn B1dgApp_2011.doc revised 06121111 CUPERTINO CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255 (408) 777 -3228 • FAX (408) 777 -3333 • buildingna.cupertino.org D,NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/ Ti ❑ REVISION /DEFERRED ORIGINAL PERMIT # PROJECT ADDRESS , ,X APN # vC Z). /) 6 e) JJ c /• OWNER NAME {� J r,.q� HONE E -MAIL 1 \ f f Q 4L, 14 -32- CL %A iye STREET ADD E S �._ CIT STATE, ZIP f FAX i �' CONTACT NAME ( �CA, 4 4 43 2__q5 `t E -MAIL STREET ADDRESS CITY, STATE, Z h ct FAX 4�1 el k OWNER ❑ OWNER- BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTORAGENT ❑ ARCHITECT Cl ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NA E 0 r' GI I n "4QLjJ&QJ LICENSE NUMBER LICENSE TYPE BUS. LIC # COMPANY NAME u E-MAIL 1116%111 1 FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARCHITE /ENGINEER NAM t. LICENSE NUMBER BUS. LIC # COMPA NAME E -MAIL ��' FAX C S `REET ADDRESS CITY, STATE, ZIP ^ C� PHONE L+ -7 A Q - I 11 DESCRIPTION OF WORK ^ C EXISTING USE PROPOSED USE CONSTR. TYPE #STORIES USE TYPE OCC. SQ.FT. VALUATION ($) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECKIPORCH AREA GARAGE AREA: 0 DETACH []ATTACH I # DWELLING UNITS: IS A SECOND UNIT ❑ YES SECOND STORY ❑ YES BEING ADDED? ❑NO ADDITION? ❑NO PRE - APPLICATION []YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YES RECE !WE Y: TOTAL VALUATION: PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER EICHLER HOME? E] NO By my signature below, 1 certify to each of the following: I am the property owner or authori .e ent to act on the property owner's behalf. I have read this application and the information I have rovided is correct. I have read the Description of Work d verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to b Iding construction. I autho * representatives of Cupertino to enter the above - identified property for inspection purposes. Signature of Applicant/Agent: Date: SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECK TYPE ROUTING SLIP ❑ OVER - THE - COUNTER ❑ BUILDING PLAN REVIEW New SFD or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUBLIC WORKS form if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FIRE DEPT Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR ❑ SANITARY SEWER DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH BldgApp 2011.doc revised 06121111 �i..1 1 1 �. I � .. Pi� -- - -- off f . ,- r SECTION 1— DESIGN VERIFICATION Complete all lines of Section 1 — 'Design Verification" and submit the completed checklist (Columns 1 and 2) with the plans and building permit application to the Building Department. The owner and design professional responsible for compliance with CalGreen Standards have revised the plans and certify that the items checked above are hereby incorporated into the project plans and will be implemented into the project in accordpince with the requirements set forth in the 2010 Califomia Green Building Standards Code as adopted by the (itypf Cupertino. Owner's Signature \�� RZ A N .1 Owner's a (Please nt) Design Professional's ignature Design P ional's e Signature o Profess' rev Name oi#i Professional responsi D += .. Email Address forA*wmsuProfeWonal C1Lc for CalGreen compliance 6 12-6 Date C, i �1 I t�— Date Dat for CalGreen compliance (Please Print) Phone for CalGreen I , I SECTION 2 — IMPLEMENTATION VERIFICATION Complete, sign and submit the competed checklist, including column 3, together with all original signatures on Sec*= 2 to the Building Department prior to Building Department final inspection. I have inspected the work and have received sufficient documentation to verify and certify that the project identified above was constructed in accordance with this Green Building Checklist and in accordance with the requirements of the 201 Green Wilding flandards Code as adopted by the City of Cupertino. Signature of License Pro I responsible for CalGreen compliance Date KAr.kl177wE��, cspa)v PoIPT -/�� 1-3 11 i Name of License Professional responsible for CalGJr�een compliance (Please Print) I'/ � j ( Phone I Email Address for License Profasslodfil responsible for CalGreen compliance 1 kp K icy` Pegs 5 of 5 CalGreen 2010.docmised 02114111 1 FILE CERTIF F D VERIFICATION & DIAGNOSTIC TESTING (Page 1 of 8) CF -4R Proje�Address Builder or Installer Name Builder or Installer Contact Telephone S M n v l 8 Lcv an/Permit (Ad itio or Alterations) Number HERS Rater Telephone ample Grou umber Compliance Method (Prescriptive) Climate one Certifying Signature Date Sample House Number Firm HERS Provider Street Address: City /State /Zip: Copies to: BUILDER, HERS PROVIDER AND BUILDING DEPARTMENT HERS RATER COMPLIANCE STATEMENT The house was: ✓ ❑ Tested ✓ ❑ Approved as part of sample testing, but was not tested As the HERS rater providing diagnostic testing and field verification, I certify that the house identified on this form complies with the diagnostic tested compliance requirements as checked ✓ on this form. The HERS rater must check and verify that the new distribution system is fully ducted and correct tape is used before a CF -4R may be released on every tested building. The HERS rater must not release the CF -4R until a properly completed and signed CF -6R has been received for the sample and tested buildings. ❑ The installer has provided a copy of CF -6R (Installation Certificate). ❑ New ducts are fully ducted (i.e., does not use building cavities as plenums or platform returns in lieu of ducts). ❑ New ducts with cloth backed, rubber adhesive duct tape is installed, mastic and draw bands are used in combination with cloth backed, rubber adhesive duct tape to seal leaks at duct connections.). ✓ ❑ MINIMUM REQUIREMENTS FOR DUCT LEAKAGE REDUCTION COMPLIANCE CREDIT Procedures for field verification and diagnostic testing of air distribution systems are available in RACM, Appendix RC4.3. Duct Diagnostic Leakage Testing Results NEW CONSTRUCTION: Residential Compliance Forms December 2005 Duct Pressurization Test Results (CFM @ 25 Pa) Measured .. Values`' 1 Enter Tested Leakage Flow in CFM: n; 3 2 Fan Flow: Calculated (Nominal: ✓ ❑ Cooling ✓ ❑ Heating) or ✓ ❑ Measured Enter Total Fan Flow in CFM: ✓ ✓ 3 Pass if Leakage Percentage < 6% [ 100 x [_(Line # I) / (Line # 2)]] ❑ Pass ❑ Fail ALTERATIONS: Duct System and /or HVAC Equipment Change -Out -` et—rie�s–ted Leakage Flow in CFM from CF -6R: Pre -Test of Existing Duct System Prior to 4 [Ent uc System Alteration and/or Equipment Change -Out. Enter Tested Leakage Flow in CFM: Final Test of New Duct System or Altered Duct System 5 for Duct System Alteration and/or Equipment Chan e -Out. Enter Reduction in Leakage for Altered Duct System [_(Line # 4) Minus (Line # 5)]' 6 (Only if Applicable)' ' 7 Enter Tested Leakage Flow in CFM to Outside (Only if Applicable) ✓ ✓ 8 Entire New Duct System - Pass if Leakage Percentage < 6% [1 Pass ❑ Fail 100 x Line # 5 / Line # 2 TEST OR VERIFICATION STANDARDS: For Altered Duct System and /or HVAC Equipment Change -Out ✓ ✓ Use one of the following four Test or Verification Standards for compliance: 9 Pass if Leakage Percentage < I5% [100 x [ (Line # 5) / (Line # 2)]] ❑ Pass ❑ Fail 10 Pass if Leakage to Outside Percentage < 10% [100 x [__(Line # 7) / (Line # 2)]] ❑ Pass ❑ Fail Pass if Leakage Reduction Percentage > 60% [100 x [_(Line # 6) / (Line # 4;1]] ❑ Pass ❑ Fail 11 and Verification by Smoke Test and Visual Inspection Pass if Sealing of all Accessible Leaks and Verification by Smoke Test and Visual Inspection I€ ;.` ❑ Pass ❑ Fail Pass if One of Lines # 9 through # 12 pass , , ❑ Pass ❑ Fail Residential Compliance Forms December 2005 CERTIFICATE OF FIELD VERIFICATION & DIAGNOSTIC TESTING (Page 2 of 8) CF -4R Project Address ilders Name Bu Copies to: BUILDER, HERS PROVIDER AND BUILDING DEPARTMENT ✓ ❑ DIAGNOSTIC SUPPLY DUCT LOCATION, SURFACE AREA AND R -VALUE Procedures for field verification and diagnostic testing for this group compliance credits are available in RACM, Appendix RC, RE & RH. ✓ ❑ LESS THAN 12 LINEAL FEET OF SUPPLY DUCT OUTSIDE OF CONDITIONED SPACE COMPLIANCE CREDIT ✓ es I ❑No I Less than 12 lineal feet of supply duct outside of conditioned space. Yes to this compliance credit is a pass ✓ ❑ Pass ✓ ❑ Fail ✓ ❑ SUPPLY DUCTS LOCATED IN CONDITIONED SPACE COMPLIANCE CREDIT ✓ IffYes I 42fNo I Ducts are located within the conditioned volume of building. Yes to this compliance credit is a pass ✓ ❑ Pass ✓ ❑ Fail 1. Supply duct surface area reduction 2. Buried supply ducts on the ceiling 3. Deeply buried supply ducts ✓ ❑ DUCT SYSTEM DESIGN VERIFICATION ✓ ❑ Yes No Adequate airflow verified ✓ ❑ Yes No lNo The duct system design plan meets the requirements specified in RACM, Appendix RE, Section RE.4.2 ✓ ❑ Yes No The duct system design plan exists on building plans ✓ ❑ Yes ❑ Duct sizes, duct system layout and locations of supply & return registers match the duct system design plan Yes to all is a pass I ✓ ❑ Pass I ✓ ❑ Fail ✓ ❑ SUPPLY DUCTS SURFACE AREA REDUCTION COMPLIANCE CREDIT Attic Crawl Space Basement Covered Deeply Covered Other Duct Diameter R-4.2 Surface Area R -6.0 Surface Area R -8.0 Surface Area ❑ Fail < I I ❑ `1 � ❑ ❑ ❑ �J L D LL J < ❑ ❑ =1' F LJ J `l L Total Surface Area for Each R -Value = ✓ ^I Yes n No Duct Surface Area matches Performance's CF -1R? ✓ ✓ Yes to all is a pass ❑ Pass ❑Fail ✓ ❑ RIIRIF.D DIICTS ON THE CEILING COMPLIANCE CREDIT ./ ❑ Yes No Buried Ducts on the Ceiling ./ ❑ Yes P1<0 Verified High Insulation Installation Quality ✓ ✓ Yes to duct system design, supply duct surface area reduction and this compliance credit is a pass ❑ Pass ❑ Fail ✓ ❑ DF.F.PI.V RURim Di1CTS CnMP1JANCF CRF.DIT ✓ Residential Compliance Forms December 2005 Ip Yes No Deeply Buried Ducts ✓ ❑ Yes No I Verified High Insulation Installation Quality ✓ ✓ Yes to ducts stem design, supply duct surface area reduction and this compliance credit is a pass ❑ Pass ❑ Fail Residential Compliance Forms December 2005 CERTIFICATE OF FIELD VERIFICATION & DIAGNOSTIC TESTING (Page 3 of 8) CF -4R Project Address Location Builder Name . � o Builder Co tart Telephone Plan Number HERS Rater Telephone Sample Group Number Btu/hr Compliance Method (Prescriptive) ✓ Climate Zone Certifying Signature Date Sample House Number Firm (must be checked monthly) HERS Provider Street Address: installation of the specific equipment shall be verified. City/State /Zip: Copies to: BUILDER, HERS PROVIDER AND BUILDING DEPARTMENT HERS RATER COMPLIANCE STATEMENT The house was: V 1 Tested ✓ ❑ Approved as part of sample testing, but was not tested As the HERS rater providing diagnostic testing and field verification, I certify that the house identified on this form complies with the diagnostic tested compliance requirements as checked on this form. ✓ ❑ The installer has provided a copy of CF -6R (Installation Certificate). ✓ ❑ THERMOSTATIC EXPANSION VALVE (TXV) Procedures for field verification of thermostatic expansion valves are available in RA CM, Appendix RI. ✓ ❑ REFRIGERANT CHARGE MEASUREMENT Verification for Required Refrigerant Char e for Split System Space Cooling Systems without Thermostatic Expansion Valves Outdoor Unit Serial # Location ✓ ✓ Outdoor Unit Model Cooling Capacity Access is provided for inspection. The procedure shall consist of Btu/hr Date of Verification ✓ ❑ Yes No visual verification that the TXV is installed on the system and ❑ ❑ (must be checked monthly) installation of the specific equipment shall be verified. Yes is a pass Pass Fail ✓ ❑ REFRIGERANT CHARGE MEASUREMENT Verification for Required Refrigerant Char e for Split System Space Cooling Systems without Thermostatic Expansion Valves Outdoor Unit Serial # Location Outdoor Unit Make Outdoor Unit Model Cooling Capacity Btu/hr Date of Verification Date of Refrigerant Gauge Calibration (must be checked monthly) Date of Thermocouple Calibration (must be checked monthly) Standard Charge Measurement (outdoor air dry -bulb 55 OF and above): Note: The system should be installed and charged in accordance with the manufacturer's specifications and installer verification shall be documented on CF -6R before starting this procedure. If outdoor air dry-bulb is below 55 °F rater shall use the Alternative Charge Measure Procedure Procedures for Determining Refrigerant Charge using the Standard Method are available in RACM, Appendix RD2. ✓ ❑ Yes ❑ No A copy of CF -6R (Installation Certificate) has been provided with refrigerant charge measurement documented. Residential Compliance Forms April 2005 CERTIFICATE OF FIELD VERIFICATION & DIAGNOSTIC TESTING (Page 4 of 8) CF -4R Project Address c Builde s Name l,oples to: nuii uEK, tI M5 rKIJV1ULKA1N1J 15U1L MENty UErAK11VILA 1 Measured Temperatures Supply (evaporator leaving) air dry-bulb temperature (Tsupply, db) OF Return (evaporator entering) air dry-bulb temperature (Tretum, db) OF Return (evaporator entering) air wet -bulb temperature (Treturn, wb) OF Evaporator saturation temperature (Tevaporator, sat) OF Suction line temperature (Tsuction, db) °F Condenser (entering) air dry-bulb temperature (Tcondenser, db) OF Superheat Charge Method Calculations for Refrigerant Charge Actual Superheat = Tsuction, db — Tevaporator, sat OF Target Superheat (from Table RD -2) °F Actual Superheat — Target Superheat (System passes if between -5 and +5 °F) °F Temperature Split Method Calculations for Adequate Airflow Split Method Calculation is not necessary ifAdepuate Airflow credit is taken Actual Temperature Split = T return, db - Tsupply, db OF Target Temperature Split (from Table RD3) OF Actual Temperature Split - Target Temperature Split (System passes if between -3 °F and OF +3 °F or, upon remeasurement, if between -3 °F and -1007 Proc Standard Charge Measurement Summary: System shall pass both refrigerant charge and adequate airflow calculation criteria from the same measurements. If corrective actions were taken, both criteria must be remeasured and recalculated ✓ ❑ Yes ❑ No System Passes Alternative Charge Measurement (outdoor air dry -bulb below 55 °F) Note: The system should be installed and charged in accordance with the manufacturer's specifications and installer verification shall be documented on CF -6R before starting this procedure. If outdoor air dry-bulb is 55 OF or above, rater shall use the Standard Charge Measure Procedure: edures or De ermining Re ri erant Charge using the Alternative Method are available in RA CM, Appendix RD3. ✓ ❑ Yes ❑ No A copy of CF -6R (Installation Certificate) has been provided with refrigerant charge measurement documented. Weigh -In Charging Method for Refrigerant Charge Actual liquid line length: Manufacturer's Standard liquid line length: Jft Difference (Actual — Standard): Manufacturer's correction (ounces per foot) x difference in length = ounces "+ " = add ounces - = remove ounces Alternative Charge Measurement Summary: System shall pass both refrigerant charge and adequate airflow calculation criteria from the same measurements. If corrective actions were taken, both criteria must be remeasured and recalculated. ✓ 111 Yes ❑ No I System Passes Residential Compliance Forms December 2005 CERTIFICATE OF FIELD VERIFICATION & DIAGNOSTIC TESTING (Page 5 of 8) CF -4R Project Address []'Yes Builder Name Builder Con t N\- Telephone 3 'Lg1CX:' Plan Number C) HERS Rater Telephone Sample Group Number Refrigerant charge or TXV Certifying Signature Date Sample House Number Firm ❑ No HERS Provider Street Address: 4 City/State /Zip: Copies to: BUILDER, HERS PROVIDER AND BUILDING DEPARTMENT HERS RATER COMPLIANCE STATEMENT The house was: ✓ ❑ Tested ✓ ❑ Approved as part of sample testing, but was not tested As the HERS rater providing diagnostic testing and field verification, I certify that the house identified on this form complies with the diagnostic tested compliance requirements as checked on this form. ✓ ❑ The installer has provided a copy of CF -6R (Installation Certificate). ✓ ❑ ADEQUATE AIRFLOW VERIFICATION Procedures for field verification and diagnostic testing of adequate airflow are available in RA CM, Appendix RE4.1. Method For Airflow Measurement ❑ Yes ❑ No ❑ RE4.1.1 ❑ RE4.1.2 ❑ RE4.1.3 Duct design exists on plans Diagnostic Fan Flow Using Diagnostic Fan Flow Using Diagnostic Fan Flow Usine Flow Capture Hood Plenum Pressure Matching Flow Grid Measurement Measured Airflow: Rated Tons: ✓ ❑ Yes I ❑ No I Measured airflow is greater than the criteria in Table RE -2 Yes is a pass Total CFM cfm/ton ✓ ✓ ❑ ❑ Pass Fail ✓ ❑ MAXIMUM COOLING CAPACITY Procedures for determining maximum rnolinQ lnad canacity are availahle in RACA11 Annendix RF3_ 1 ✓ []'Yes ❑ No Adequate airflow verified (see adequate airflow credit) 2 ✓ ❑"Yes ❑ No Refrigerant charge or TXV ✓ 3 3 eYes ❑ No Duct leakage reduction credit verified Time Delay Relay Verified (If Required) 4 ❑ C17Yes ❑ No Cooling capacities of installed systems are <_ to maximum cooling capacity indicated on the Performance's CF -1 R and RF -3. ✓ ❑ Yes 0-'No If the cooling capacities of installed systems are > than maximum cooling capacity in the CF -1 R, then the electrical input for the installed systems must be <_ to electrical input in the CF -1 R and RF -4. V/ V/ ❑ Yes to 1, 2, and 3; and Yes to either 4 or 5 is a pass Pass Fail ✓ ❑ HIGH EER AIR CONDITIONER Prnredurpv for verification are availahle in RACAL Annendix Rl. 1 ✓ ❑ Yes ❑ No EER values of installed systems match the CF -1 R 2 ✓ ❑ Yes ❑ No For split system, indoor coil is matched to outdoor coil ✓ ✓ 3 ✓ ❑ Yes ❑ No Time Delay Relay Verified (If Required) ❑ ❑ Yes to 1 and 2; and 3 (If Required) is a pass Pass Fail Residential Compliance Forms December 2005 CERTIFICATE OF FIELD VERIFICATION & DIAGNOSTIC TESTING (Page 6 of 8) CF -4R Project Address �c� • ,/CL- Builder Name W --&r" 0. Builder Contact o ry i Telephone o° ,—I C�- -p Plan Number HERS Rater Telephone Sample Group Number Enter results of Watts /cfm: Certifying Signature Date Sample House Number Firm ❑ No HERS Provider Street Address: If Mechanical Ventilation is required on the CF -1 R (Yes in line 2), has it been City/State /Zip: Copies to: BUILDER, HERS PROVIDER AND BUILDING DEPARTMENT HERS RATER COMPLIANCE STATEMENT The house was: ✓ ❑ Tested ✓ ❑ Approved as part of sample testing, but was not tested As the HERS rater providing diagnostic testing and field verification, I certify that the house identified on this form complies with the diagnostic tested compliance requirements as checked on this form. ✓ ❑ The installer has provided a copy of CF -6R (Installation Certificate). ✓ ❑ FAN WATT DRAW Procedures for measurinz the air handler watt draw are available in RACM. Avnendix RE3.2. ✓ Method For Fan Watt Draw Measurement ❑ RE3.2.1 Portable Watt Meter Measurement ❑ RE3.2.2 Utility Revenue Meter Measurement Measured Fan watt Draw: (enter watts here Measured Fan Flow Enter total cfm from airflow verification Enter results of Watts /cfm: ❑ Yes ❑ No Is Mechanical Ventilation shown as required on the CF -1R? ✓ ❑ Yes ❑ No Calculated fan watt/cfm is equal to or lower than the fan watt/cfm draw documented in CF -1 R Yes is a HERS RATER COMPLIANCE STATEMENT The house was: ✓ ❑ Tested ✓ ❑ Approved as part of sample testing, but was not tested Watts cfm Watts /cfm ✓ ✓ Pass As the HERS rater providing diagnostic testing and field verification, I certify that the house identified on this form complies with the diagnostic tested compliance requirements as checked on this form. ✓ ❑ The installer has provided a copy of CF -6R (Installation Certificate). ✓ ❑ MINIMUM REQUIREMENTS FOR INFILTRATION REDUCTION COMPLIANCE CREDIT Procedures for field verification and diagnostic testing of infiltration reduction are available in RACMSection 3.5. Diagnostic Testing Results Residential Compliance Forms April 2005 ✓ ✓ Building Envelope Leakage (CFM @ 50 Pa) as measured by Rater: 1. ❑ Yes ❑ No Is measured envelope leakage less than orequal to the required level from CF -1 R? 2. ❑ Yes ❑ No Is Mechanical Ventilation shown as required on the CF -1R? 2a. ❑ Yes ❑ No If Mechanical Ventilation is required on the CF -1 R (Yes in line 2), has it been installed? 2b. ❑ Yes ❑ No Check this box yes if mechanical ventilation is required (Yes in line 2) and ventilation fan watts are no greater than shown on CF -IR. Check this box yes if measured building infiltration (CFM @ 50 Pa) is greater than 3. ❑ Yes ❑ No the CFM @ 50 values shown for an SLA of 1.5 on CF -1R If this box is checked no, mechanical ventilation is required.) Check this box yes if measured building infiltration (CFM @ 50 Pa) is less than the 4. ❑ Yes ❑ No CFM @ 50 values shown for an SLA of 1.5 on CF -1R, mechanical ventilation is installed and house pressure is greater than minus 5 Pascal with all exhaust fans operating. ✓ ✓ Pass if: a) Yes in line 1 and line 3, or b) Yes in line I and line2, 2a, and 2b, or c)Yes in line 1 and ❑ ❑ line 4, Otherwise Fail. Pass Fail Residential Compliance Forms April 2005 CERTIFICATE OF FIELD VERIFICATION & DIAGNOSTIC TESTING (Page 7 of 8) CF -4R Project Address to �„`�a r^ Jam. Builder Name C Builder Contact , no r Telego}nee 0 Plan Numbe HERS Rater Telephone Sample Group Number ❑ Certifying Signature Date Sample House Number Firm HERS Provider Street Address: ET Yes City/State /Zip: Copies to: BUILDER, HERS PROVIDER AND BUILDING DEPARTMENT HERS RATER COMPLIANCE STATEMENT The house was: ✓ ❑ Tested ✓ ❑ Approved as part of sample testing, but was not tested As the HERS rater providing diagnostic testing and field verification, I certify that the house identified on this form complies with all applicable requirements of the "High Quality Installation of Insulation" protocols as specified in the Residential ACM, Appendix RH and as checked on this form. Note that to PASS and receive compliance credit, NONE of the BOXES below may be checked "No" and the first three boxes also must be checked. Check "NA" only if the item is not part of the design of the building (i.e., single story buildings do not have rim joists or there may be no recessed can lights installed, etc.). ✓ ❑ REQUIREMENTS FOR "HIGH QUALITY INSTALLATION OF INSULATION" COMPLIANCE CREDIT ✓ ❑ The building is wood frame construction with wall stud cavities, ceilings, and roof assemblies insulated with mineral fiber or cellulose insulation in low -rise residential buildings. ✓ ❑ Description of insulation, (CF -6R, formerly IC -1) signed by the installer stating: insulation manufacturer's name, material identification, installed R- values, and for loose -fill insulation: minimum weight per square foot and minimum inches. ✓ ❑ Installation Certificate, (CF -6R) signed by the installer certifying that the installation meets all applicable requirements as specified in the High Quality Insulation Installation Procedures (ACM, Appendix RH). ✓ FXOOR Y Yes ❑ ` No ❑ NA All floor joist cavity insulation installed to uniformly fit the cavity side -to -side and end -to -end Yes ❑ No ❑ NA Insulation in contact with the subfloor or rim joists insulated ❑ ❑ Insulation properly supported to avoid gaps, voids, and compression es No NA ✓ ALLS ET Yes ❑ No ❑ NA Wall stud cavity insulation uniformly fills the cavity side -to -side, top -to- bottom, and front -to -back Yes ❑ No ❑ NA No gaps e ❑ No ❑ NA No voids over 3/4" deep or more than 10% of the batt surface area. ❑ ❑ Hard to access wall stud cavities such as; corner channels, wall intersections, and behind tub /shower Yes No NA enclosures insulated to proper R -Value Yes ❑ No ❑ NA Small spaces filled ❑ No ❑ NA Rim - joists insulated Yes ❑ No ❑ NA Wall stud cavities caulked or foamed to provide an air tight envelope Residential Compliance Forms April 2005 CERTIFICATE OF FIELD VERIFICATION & DIAGNOSTIC TESTING (Page 8 of 8) CF -4R Project Address Build rs Name Cr—� ( &< <'-- o ✓ OOF /CEILING PREPARATION Ye . ❑ No ❑ NA All draft stops in place to form a continuous ceiling and wall air barrier Y ❑ No ❑ NA All drops covered with hard covers Ye ❑ No ❑ NA All draft stops and hard covers caulked or foamed to provide an air tight envelope . No ❑ ❑ All recessed light fixtures IC and air tight (AT) rated and sealed with a gasket or caulk between the Y9s No NA housing and the ceiling In s ❑ No ❑ NA Floor cavities on multiple -story buildings have air tight draft stops to all adjoining attics Yes ❑ No NA Eave vents prepared for blown insulation - maintain net free - ventilation area ❑ Yes ❑ No N Knee walls insulated or prepared for blown insulation ❑ Yes ❑ No NA , Area under equipment platforms and cat -walks insulated or accessible for blown insulation ❑ Yes ❑ No A Attic rulers installed ✓]&OOF /CEILING BATTS Ye ❑ No ❑ NA No gaps Ye ❑ No ❑ NA No voids over 3/4 in. deep or more than 10% of the batt surface area Yes ❑ No .1 ❑ NA Insulation in contact with the air - barrier ❑ Yes . No ❑ NA Recessed light fixtures covered Yes ❑ No ❑ NA Net free - ventilation area maintained at eave vents ✓ ROOF /CEILING LOOSE -FILL Yes ❑ No ❑ NA Insulation uniformly covers the entire ceiling (or roof) area from the outside of all exterior walls Yes ❑ No ❑ NA Baffles installed at eaves vents or soffit vents - maintain net free- ventilation area of eave vent ❑ Yes No ❑ NA Attic access insulated V Yes ❑ No ❑ NA Recessed light fixtures covered ❑ Yes ❑ No ❑ NA Insulation at proper depth — insulation rulers visible and indicating proper depth and R -value Loose -fill mineral fiber insulation meets or exceeds manufacturer's minimum weight and thickness ❑ ❑ Q/ requirement for the target R- value. Target R -value 1 �" _ _ Manufacturer's Yes No NA minimum required weight for the target R -value (pounds -per- square foot). Sample weight (pounds per square foot). Manufacturer's minimum required thickness at time of installation Z _ (_ _k 0 (inches) Manufacturer's minimum required settled thickness I _(— —k y (inches). Number of days since loose -fill insulation was installed (days). At the time of installation, the insulation ❑ shall be greater than or equal to the manufacturer's minimum initial insulation thickness. If the HERS Yes No NA rater does not verify the insulation at the time of installation, and if the loose -fill insulation has been in place less than seven days the thickness shall be greater than the manufacturer's minimum required thickness at the time of installation less 1/2 inch to account for settling. If the insulation has been in place for seven days or longer the insulation thickness shall be greater than or equal to the manufacturer's minimum required settled thickness. Minimum thickness measured (inches). Residential Compliance Forms April 2005 INSTALLATION CERTIFICA E (Page 1 of-12) F -6R Site ddress Permit Number Insta �Iation certificates (CF -6R) are re fired for each and every dwelling unit. When t e installation of measures that equire field rification and diagnostic testin is complete, the builder or the builder's subcontr for shall complete dia tic testing end the procedures specifie n this section. When the installation is complete, the bitilde, or th s subcontractor shall complete the F -6R (Installation Certificate), and keep it at the building site for review by the building department' : The builder alsp sall provide a copy of the Installation Certificate to the HERS rater for any measures requiring field verification and di'aenostic testine. ner Section 10- 103(a). WATER HEATING SYSTEMS: Heater T e CEC Certified Mfr Name & Model umber Distribution Type - (Std, Point- of -Use, -etc If Recirculation, Control Type # of Identical Systems Rated Input (kW or Bt./hr)' Tank Volume (gallons) Efficiency (EF, RE 2 Standby Loss ( %)2 External Insulation R -value .� fG Or C I For small gas storage (rated input of less than or equal to 75,000 Btu/hr), electric resistance and heat pump water heaters, list Energy Factor (EF). For large gas storage water heaters (rated input of greater than 75,000 Btu /hr), list Recovery (RE), Thermal Efficiency, Standby Loss and Rated Input. For instantaneous gas water heaters, list Thermal Efficiency and Rated Input. 2. R -12 external insulation is mandatory for storage water heaters with an energy factor of less than 0.58. Kitchen Piping: If indicated on the CF -1 R, all hot water piping > 3/4 inches in diameter that runs from the hot water source to the kitchen fixtures is insulated. Faucets & Shower Heads: All faucets and showerheads installed are certified to the Energy Commission, pursuant to Title 24, Part 6, Section 111. Central Water Heating in Buildings with Multiple Dwelling Units (required for prescriptive) ��Allhot water piping in main circulating loop is insulated to requirements of § 1500) ❑Central hot water systems serving six or fewer dwelling units which have (1) less than 25' of distribution piping outdoors; (2) zero distribution piping underground; (3) no recirculation pump; and (4) insulation on distribution piping that meets the requirements of Section 1500) ❑Central hot water systems serving more than 6 dwelling units - presence of either a time control or a time /temperature control ✓ IQ I, the undersigned, verify that equipment listed above my signature is: 1) the actual equipment installed; 2) 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) equipment that meets or exceeds the appropriate requirements for manufactured devices (from the Appliance Effiiciency Regulations or Part 6), where applicable. Installing Subcontractor (Co. Name) OR General Contractor (Co. Name) OR Owner C e.�`, �- 0 ( n\ 0, t—, O Signature: Date: Copies to: BUILDING DEPARTMENT, HERS RATER (IF APPLICABLE) BUILDING OWNER AT OCCUPANCY Residential Compliance Forms September 2005 INSTALLATION CERTIFICATE (Page 2 of 12) CF -6R Site Address Permit Number V s -V C"V V - 1 *1-0 --L n 02 0 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) 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(a). FENESTRATION /GLAZING: Item Manufacturer/Brand Name (GROUP LIKE RODUCTS Product U- factor ( <_ CF -1R value) Product SHGC' ( <_CF -lR value)` # of Panes Total Quantity of Like Product (Optionao Area Square Feet Exterior Shading Device or Overhang Comments /Location/ Special Features 1. OR Window Distributor Item #s Signature Date Installing Subcontractor (Co. Name) OR (if applicable) General Contractor (Co. Name) OR Owner 2. OR Window Distributor 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. l Use values from a fenestration product's NFRC label. For fenestration products without an NFRC label, use the default values from Section 116 of the Energy Efficiency Standards. 2) Installed U- factor must be less than or equal to values from CF -1 R. Installed SHGC must be less than or equal to values from CF -1R, or a shading device (exterior or overhang) is installed as specified on the CF -1R. Alternatively, installed weighted average U- factors for the total fenestration area are less than or equal to values from CF -1R. If using default table SHGC va es from § 116 identify whether tinted or not. ✓ I, the undersigned, verify that the fenestration/glazing listed above my signature: 1) is the actual fenestration product installed; 2) is equivalent to or has a lower U- factor and lower SHGC than that specified in the certificate of compliance (Form CF -1R) submitted for compliance with the Energy Efficiency Standards for residential buildings; and 3) the product meets or exceeds the appropriate requirements for manufactured devices (from Part 6), where applicable. Item #s (if applicable) Signature Date Installing Subcontractor (Co. Name) OR General Contractor (Co. Name) OR Owner OR Window Distributor Item #s Signature Date Installing Subcontractor (Co. Name) OR (if applicable) General Contractor (Co. Name) OR Owner OR Window Distributor Item #s Signature Date Installing Subcontractor (Co. Name) OR (if applicable) General Contractor (Co. Name) OR Owner OR Window Distributor Copies to: Building Department, HERS Rater (if applicable) Building Owner at Occupancy Residential Compliance Forms April 2005 INSTALLATION CERTIFICATE (Page 3 of 12) CF -6R Site Address Permit Number 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) 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(a). HVAC SYSTEMS: Heating Equipment Equip Type (pkg. heat lln] CEC Certified Mfr. Name and Model Number # of Identical Systems Efficiency � (AFUE, etc.) (?CF- I R value) Duct Location ( aftic, etc" ) Duct or Piping R -value Heating Load (Btu/hr ) Heating Capacity (Btu/hr IQ-* y C11-1 i ij3hMNO(o if Cooling Equipment Equip Type (pkg. heat um CEC Certified Mfr. Name and Model Number # of Identical Systems Efficiency t (SEER or EER) ?CF- IRvalue) Duct Location attic, etc. Duct R -value Cooling Load (Btu/hr ) Cooling Capacity (Btu /hr IQ-* y C11-1 i ij3hMNO(o if 1. > symbol reads greater than or equal to what is indicated on the CF -11? value. ;;1 ude oth SEER and EER if compliance credit for high EER air conditioner is claimed. ✓ I, the undersigned, verify that equipment Iisted above is: 1) is the actual equipment installed, 2) equivalent to or more efficient than that specified in the certificate of compliance (Form CF -1R) 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. Installing Subcontractor (Co. Name) OR General Contractor (Co. Name) OR Owner Signature: Date: Copies to: BUILDING DEPARTMENT, HERS RATER (IF APPLICABLE) BUILDING OWNER AT OCCUPANCY Residential Compliance Forms April 2005 INSTALLATION CERTIFICATE (Page 4 of 12) CF -6R Site Address Permit Number o' {{ 'p �o �s K M0 .. d INSTALLER COMPLIANCE STATEMENT FOR DUCT LEAKAGE INSTALLER COMPLIANCE STATEMENT The building was: ✓ ❑Tested at Final ✓ ❑ Tested at Rough -in IN A ALLER VISUAL INSPECTION AT FINAL CONSTRUCTION STAGE FOR NEW DUCTS: Remove at least one supply and one return register, and verify that the spaces between the register boot and the interior finishing wall are properly sealed. e house rough -in duct leakage test was conducted without an air handler installed, inspect the connection points between the it handler and the supply and return plenums to verify that the connection points are properly sealed. Inspect all joints to ensure that no cloth backed rubber adhesive duct tape is used on new ducts. ✓ ❑ DUCT LEAKAGE REDUCTION Procedures for field verification and diagnostic testing of air distribution systems are available in RACM, Appendix RC4.3 NEW CONSTRUCTION: Duct Pressurization Test Results (CFM @ 25 Pa) Measured ME. Values�,: 1 Enter Tested Leakage Flow in CFM: , Fan Flow: Calculated (Nominal: ✓ ❑ Cooling ✓ ❑ Heating) or ✓ ❑ Measured 2 If Fan Flow is Calculated as 400 cfm/ton x number of tons or as 21.7 cfm/(kBtu/hr) x Heating Capacity in Thousands of Btu/hr, enter total calculated or measured fan flow in CFM here: ✓ ✓ 3 Pass if Leakage Percentage < 6% for Final or < 4% at Rough -in without air handle: ❑Pass ❑Fail 100 x Line # 1 / Line # 2 ALTERATIONS: Duct System and /or HVAC Equipment Change -Out M Enter Tested Leakage Flow in CFM from Pre -Test of Existing Duct System Prior to Duct 4 System Alteration and/or Equipment Change -Out. v Enter Tested Leakage Flow in CFM from Final Test of New Duct System or Altered Duct 5 System for Duct System Alteration and /or Equipment Chan e -Out. Enter Reduction in Leakage for Altered Duct System 6 Line # 4 Minus Line # 5 — (Only if Applicable) 7 Enter Tested Leakage Flow in CFM to Outside (Only if Applicable) ✓ ✓ Entire New Duct System - Pass if Leakage Percentage < 6% for Final. ❑ Pass ❑ Fail 8 -100 x Line # 5 / Line # 2 TEST OR VERIFICATION STANDARDS: For Altered Duct System and /or HVAC Equipment Change- ✓ ✓ Out Use one of the following four Test or Verification Standards for compliance: 9 Pass if Leakage Percentage < 15% [100 x [ (Line # 5) / (Line # 2)]] ❑ Pass ❑ Fail 10 Pass if Leakage to Outside Percentage < 10% [100 x L (Line # 7) / (Line # 2)]] ❑ Pass ❑ Fail Pass if Leakage Reduction Percentage > 60% [100 x [_(Line # 6) / (Line # 4)]] ❑ Pass ❑ Fail 11 and Verification by Smoke Test and Visual Inspection 12 Pass if Sealing of all Accessible Leaks and Verification by Smoke Test and Visual Inspection ❑ Pass ❑ Fail Pass if One of Lines # 9 through # 12 as ': ❑Pass ❑Fail ✓ 111, the undersigned, verify that the above diagnostic test results were performed in conformance with the requirements for compliance credit. I, the undersigned, also certify that the newly installed or retrofit Air - Distribution System Ducts, Plenums and Fans comply with Mandatory requirements specified in Section 150 (m) of the 2005 Building Energy Efficiency standards. Installing Subcontractor (Co. Name) OR General Contractor (Co. Name) OR Owner Signature: Date: Copics to: BUILDING DEPARTMENT, HERS RATER (IF APPLICABLE) BUILDING OWNER AT OCCUPANCY Residential Compliance Forms December 2005 ✓ ❑ THERMOSTATIC EXPANSION VALVE (TXV) Procedures for field verification of thermostatic expansion valves are available in RA CM, Appendix RL ✓ ✓ v'0 REFRIGERANT CHARGE MEASUREMENT Verification for Required Refrigerant Charge and Adequate Airflow for Split System Space Cooling Systems without Thermostatic Expansion Valves Outdoor Unit Serial # Location Access is provided for inspection. The procedure shall Outdoor Unit Make OF Outdoor Unit Model Cooling Capacity consist of visual verification that the TXV is installed on Btu /hr Date of Verification ✓ ❑ Yes ❑ No the system and installation of the specific equipment ❑ ❑ (must be checked monthly) shall be verified. Yes is a pass I Pass I Fail v'0 REFRIGERANT CHARGE MEASUREMENT Verification for Required Refrigerant Charge and Adequate Airflow for Split System Space Cooling Systems without Thermostatic Expansion Valves Outdoor Unit Serial # Location Return (evaporator entering) air dry-bulb temperature (Treturn, db) Outdoor Unit Make OF Outdoor Unit Model Cooling Capacity Evaporator saturation temperature (Tevaporator, sat) Btu /hr Date of Verification Suction line temperature (Tsuction, db) Date of Refrigerant Gauge Calibration OF (must be checked monthly) Date of Thermocouple Calibration °F (must be checked monthly) Standard Charge Measurement Procedure (outdoor air dry-bulb 55 °F and above): Procedures for Determining Refrigerant Charge using the Standard Method are available in RACM, Appendix RD2. Note: The system should be installed and charged in accordance with the manufacturer's specifications before starting this procedure. Measured Temperatures Supply (evaporator leaving) air dry-bulb temperature (Tsupply, db) OF Return (evaporator entering) air dry-bulb temperature (Treturn, db) OF Return (evaporator entering) air wet -bulb temperature (Tretum, wb) OF Evaporator saturation temperature (Tevaporator, sat) OF Suction line temperature (Tsuction, db) OF Condenser (entering) air dry-bulb temperature ( Toondenser, db) °F Superheat Charge Method Calculations for Refrigerant Charge Actual Superheat = Tsuction, db — Tevaporator, sat °F Target Superheat (from Table RD -2) OF Actual Superheat — Target Superheat (System passes if between -5 and +5 °F) 'F Temperature Split Method Calculations for Adequate Airflow Split Method Calculation is not necessary i Ade uate Air ow credit is taken Actual Temperature Split = T return, db Tsupply, db OF Target Temperature Split (from Table RD3) OF Actual Temperature Split Target Temperature Split (System passes if between - of 3 °F and +3 °F or, upon remeasurement, if between -3 °F and -100 °F Residential Compliance Forms April 2005 INSTALLATION CERTIFICATE (Page 6 of 12) CF -6R Site Address Permit Number o �..� Standard Charge Measurement Summary: System shall pass both refrigerant charge and adequate airflow calculation criteria from the same measurements. If corrective actions were taken, both criteria must be remeasured and recalculated. ✓ ❑ Yes ❑ No I System Passes Alternate Charge Measurement Procedure (outdoor air dry-bulb below 55 °F) Note: The system should be installed and charged in accordance with the manufacturer's specifications and installer verification shall be documented on CF -6R before starting this procedure. If outdoor air dry-bulb is 55 OF or above, installer shall use the Standard Charge Measure Procedure: Procedures, for Determining Refrigerant Charge using the Alternate Method are available in RA CM, Appendix RD3. Weigh -In Charging Method for Refrigerant Charge Actual liquid line length: ft Manufacturer's Standard liquid line length: ft Difference (Actual — Standard): ft Manufacturer's correction (ounces per foot) x difference in length = ounces (+ = add) (- = remove) leasured Airflow Method for Adequate Airflow Verification available in RACM, Appendix RD2.6 Calculated Airflow: Cooling Capacity (Btu/hr) X 0.033 (cfm/Btu -hr) = CFM Measured Airflow is CFM (Measured airflow must be greater than the calculated airflow). Alternate Charge Measurement Summary: System shall pass both refrigerant charge and adequate airflow calculation criteria from the same measurements. If corrective actions were taken, both criteria must be remeasured and recalculated. ✓ 10 Yes 10 No I System Passes Installing Subcontractor (Co. Name) OR General Contractor (Co. Name) OR Owner Signature: Date: Copies to: BUILDING DEPARTMENT, HERS RATER (IF APPLICABLE) BUILDING OWNER AT OCCUPANCY Residential Compliance Forms April 2005 INSTALLATION CERTIFICATE (Page 7 of 12) CF -6R Site Address Permit Number MISCELLANEOUS CREDITS ✓ ❑ DIAGNOSTIC SUPPLY DUCT LOCATION, SURFACE AREA AND R- VALUE Procedures for field verification and diagnostic testing for this group compliance credits are available in RACM, Appendix RC, RE & RH. ✓ ❑ LESS THAN 12 LINEAL FEET OF SUPPLY DUCT OUTSIDE OF CONDITIONED SPACE CO PLIANCE CREDIT ✓ es I []No I Less than 12 lineal feet of supply duct outside of conditioned space. Yes to this compliance credit is a pass ✓ ❑ Pass ✓ ❑ Fail ✓ ❑ SUPPLY DUCTS LOCATED IN CONDITIONED SPACE COMPLIANCE CREDIT ✓ Yes ❑ No Ducts are located within the conditioned volume of building. Yes to this compliance credit is a pass ✓ ❑ Pass ✓ ❑ Fail Duct System Design verification is required for a compliance credit for the following: 1. Supply duct surface area reduction 2. Buried supply ducts on the ceiling 3. Deeply buried supply ducts ✓ ❑DUCT SYSTE IDESIGN VERIFICATION ✓ ❑ Yes If No Adequate airflow verified ✓ ❑ Yes o The duct system design plan meets the requirements specified in RACM, Appendix RE, Section RE.4.2 ✓ ❑ Yes o The duct system design plan exists on building plans ✓ ❑ Yes Duct Duct sizes, duct system layout and locations of supply & return registers match the duct system design plan Yes to all is a pass ✓ ❑ Pass ✓ ❑Fail ✓ ❑ SUPPLY DUCTS SURFACE AREA REDUCTION COMPLIANCE CREDIT Attic Crawl S ace Basement Covered Deeply Covered Other Duct Diameter R-4.2 Surface Area R -6.0 Surface A ea R -8.0 Surface Area I ❑ Pass 10 Fail 7 F G ❑ to VL _1 7 L C -1 -1 o Total Surface Area for Each R -Value = ✓ -1 Yes No tches Performance's CF -1R? Yes to all is a pass I Pass Fail ✓ ❑ BURIED DUCT -S ON THE CEILING COMPLIANCE CREDIT ✓ ❑ DEEPLY BIJRIP,fS DUCTS COMPLIANCE CREDIT ✓ ❑ Yes No Buried Ducts on the Ceiling ✓ ❑ Yes ❑ No Verified High Insulation Installation Quality ✓ ✓ Yes to ducts stem design, supply duct surface area reduction and this compliance credit is a pass ❑ Pass 10 Fail ✓ ❑ DEEPLY BIJRIP,fS DUCTS COMPLIANCE CREDIT ✓ ❑ Yes No Deeply Buried Ducts ✓ ❑ Yes ❑ No Verified High Insulation Installation Quality ✓ ✓ Yes to ducts stem design, supply duct surface area reduction and this compliance credit is a pass ❑Pass ❑ Fail Copies to: BUILDING DEPARTMENT, HERS RATER (IF APPLICABLE) BUILDING OWNER AT OCCUPANCY Residential Compliance Forms April 2005 INSTALLATION CERTIFICATE (Page S of 12) CF -6R Site Address Permit Number d fo 3 c� ✓❑ FAN WATT DRAW Procedures for measuring the air handler watt draw are available in RACM, Appendix RE3.2. ✓ Method For Fan Watt Draw Measurement ✓ ❑ RE3.2.1 Portable Watt Meter Measurement 2 ❑ RE3.2.2 Utility Revenue Meter Measurement Refrigerant charge or TXV ❑ RE4.1.3 Diagnostic Fan Flow Using Flow Grid Measurement ❑ No Measured Fan Watt Draw ❑ No Measured Fan Flow (enter total cfm from airflow verification) ❑ Yes Enter results of Watts /cfm Measured Airflow: 5 ✓ Rated. Tons cfm/ton ❑ No ✓ ❑ Yes ❑ No Measured fan watt/cfm draw is equal to or lower than the fan watt/cfm draw documented in CF -1R ❑ ❑ ❑ No Measured airflow is greater than the criteria in Table RE -2 Yes is a ass Pass Fail ✓ ❑ ADEQUATE AIRFLOW VERIFICATION Procedures . for measuring the airflow are available in RACM, Appendix RE3.1. ✓ Method For Airflow Measurement ✓ ❑ RE4.1.1 Diagnostic Fan Flow Using Flow Capture Hood 2 ❑ RE4.1.2 Diagnostic Fan Flow Using Plenum Pressure Matching Refrigerant charge or TXV ❑ RE4.1.3 Diagnostic Fan Flow Using Flow Grid Measurement ❑ No ❑ Yes ❑ No Duct design exists on plans ❑ Yes ❑ No Measured Airflow: 5 ✓ Rated. Tons cfm/ton ❑ No If the cooling capacities of installed systems are > than maximum ✓ ✓ cooling capacity in the CF -1R, then the electrical input for the installed systems must be 5 to electrical input in the CF -1R. ❑ ❑ Fail Yes to 1, 2, and 3; and Yes to either 4 or 5 is a pass ✓ ❑ Yes ❑ No Measured airflow is greater than the criteria in Table RE -2 ✓ ✓ Yes is a pass I Pass Fail ✓ ❑ MAXIMUM COOLING CAPACITY Procedures for determining maximum cooling load capacity are available in RACM, Appendix RF3. Watts cfm Watts /cfm Total cfm cfm/ton 1 ✓ ❑ Yes ❑ No Adequate airflow verified (see adequate airflow credit) 2 ✓ ❑ Yes ❑ No Refrigerant charge or TXV 3 ✓ ❑ Yes ❑ No Duct leakage reduction credit verified 4 ✓ ❑ Yes ❑ No Cooling capacities of installed systems are <_ to maximum cooling capacity indicated on the Performance's CF -1 R and RF -3. 5 ✓ ❑ Yes ❑ No If the cooling capacities of installed systems are > than maximum ✓ ✓ cooling capacity in the CF -1R, then the electrical input for the installed systems must be 5 to electrical input in the CF -1R. ❑ ❑ Fail Yes to 1, 2, and 3; and Yes to either 4 or 5 is a pass Pass Fail ✓❑ HIGH EER AIR CONDITIONER Procedures or veri ication are available in RACM, Appendix RI. I ✓ ❑ Yes ❑ No EER values of installed systems match the CF -1R 2 ✓ ❑ Yes ❑ No For split system, indoor coil is matched to outdoor coil ✓ ✓ 3 ✓ ❑ Yes ❑ No Time Delay Relay Verified (If Required) 11 Yes to 1 and 2; and 3 (If Required) is a pass Pass Fail Installing Subcontractor (Co. Name) OR General Contractor (Co. Name) OR Owner Signature: Date: Copies to: BUILDING DEPARTMENT, HERS RATER (IF APPLICABLE) BUILDING OWNER AT OCCUPANCY Residential Compliance Forms April 2005 INSTALLATION CERTIFICATE (Page 9 of 12) CF -6 Site Address Permit Number 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) 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(a). BUILDING ENVELOPE LEAKAGE DIAGNOSTICS ✓ ❑ ENVELOPE SEALING INFILTRATION REDUCTION Procedures for field ver,ication and diagnostic testing of envelope leakage are available in RA CM, Appendix RC. Diagnostic Testing Results ✓ ✓ Building Envelope Leakage (CFM @ 50 Pa) as measured by Rater: 1 ❑ ❑ Measured envelope leakage less than or equal to the required level from Yes No CF -1 R? ❑ ❑ 2. Is Mechanical Ventilation shown as required on the CF -1R? Yes No 2a ❑ ❑ If Mechanical Ventilation is required on the CF -1 R (`Yes' in line 2), has it Yes No been installed? El El Check this box `yes' if mechanical ventilation is required (`Yes' in line 2) 2b. and ventilation fan watts are no greater than shown on CF -1 R. Yes No Measured Watts = El El Check this box "yes" if measured building infiltration (CFM @ 50 Pa) is 3. greater than the CFM @ 50 values shown for an SLA of 1.5 on CF -1R Yes No If this box is checked no, mechanical ventilation is required.) Check this box "yes" if measured building infiltration (CFM @ 50 Pa) is 4 ❑ ❑ less than the CFM @ 50 values shown for an SLA of 1.5 on CF -1R, Yes No mechanical ventilation is installed and house pressure is greater than minus 5 Pascal with all exhaust fans operating. Pass if: a. Yes in line 1 and line 3, or ✓ ✓ b. Yes in line 1 and line2, 2a, and 2b, or c. Yes in line 1 and Yes in line 4. ❑ ❑ Otherwise fail. Pass Fail ✓ 1:11, the undersigned, verify that the building envelope leakage meets the requirements claimed for building leakage reduction below default assumptions as used for compliance on the CF -1R. This is to certify that the above diagnostic test results and the work 1 performed associated with the test(s) is in conformance with the requirements for compliance credit. (The builder shall provide the HERS provider a copy of the CF -6R signed by the builder employees or subcontractors certifying that diagnostic testing and installation meet the requirements for compliance credit.) Test Performed Installing Subcontractor (Co. Name) OR General Contractor (Co. Name) OR Owner Signature: Date: Copies to: BUILDING DEPARTMENT, HERS RATER (IF APPLICABLE), BUILDING OWNER AT OCCUPANCY Residential Compliance Forms April 2005 INSTALLATION CERTIFICATE (Page 10 of 12) CF -6R Site Address Permit Number Insulation Installation Quality Certificate ✓ ❑ Description of Insulation, (CF -6R, formerly IC -1) signed by the installer stating: insulation manufacturer's name, material identification, installed R- values, and for loose -fill insulation: minimum weight per square foot and minimum inches ✓ ❑ Installation meets all applicable requirements as specified in the High Quality Insulation Installation Procedures (ACM, Appendix RH) ✓ F OOR Yes ❑ No ❑ NA All floor joist cavity insulation installed to uniformly fit the cavity side -to -side and end -to -end ❑ ❑ Insulation in contact with the subfloor or rim joists insulated Y No NA Yes ❑ I No ❑ NA Insulation properly supported to avoid gaps, voids, and compression ✓ WALLS ❑ ❑ Wall stud cavities caulked or foamed to provide an air tight envelope Yes No NA ❑ ❑ Yes No NA Wall stud cavity insulation uniformly fills the cavity side -to -side, top -to- bottom, and front -to -back ❑ 0 ❑ Yes No NA No gaps ❑ ❑ ❑ Yes No NA No voids over 3/4" deep or more than 10% of the batt surface area. ❑ ❑ ❑ Hard to access wall stud cavities such as; corner channels, wall intersections, and behind Yes No NA tub /shower enclosures insulated to proper R -Value ❑ ❑ ❑ Small spaces filled Yes No NA ❑ ❑ ❑ Yes No NA Rim joists insulated ❑ ❑ ❑ Loose fill wall insulation meets or exceeds manufacturer's minimum weight -per- square -foot Yes I No I NA I requirement ✓ OF /CEILING PREPARATION ❑ ❑ All draft stops in place to form a continuous ceiling and wall air barrier Yes No NA ❑ ❑ ❑ All drops covered with hard covers Ye No NA ❑ ❑ All draft stops and hard covers caulked or foamed to provide an air tight envelope Yes No I NA ❑ ❑ All recessed light fixtures IC and air tight (AT) rated and sealed with a gasket or caulk between the Yes No NA housing and the ceiling Y❑es 0 NA Floor cavities on multiple -story buildings have air tight draft stops to all adjoining attics ❑ ❑ Eave vents prepared for blown insulation - maintain net free - ventilation area Yes No NA ❑ ❑ Knee walls insulated or prepared for blown insulation Yes No NA ❑ ❑ Area under equipment platforms and cat -walks insulated or accessible for blown insulation Yes No N ❑ ❑ Yes No NA Attic rulers installed Residential Compliance Forms April 2005 INSTALLATION CERTIFICATE (Page 11 of 12) CF -6R Site Address Permit Number ✓ ROB' /CEILING BATTS DECLARATION ✓ ❑ 1 hereby certify that the installation meets all applicable requirements as specified in the Insulation Installation Procedures. Installing Subcontractor (Co. Name) OR General Contractor (Co. Name) OR Owner Signature: Date: Copies to: BUILDING DEPARTMENT, HERS RATER (IF APPLICABLE), BUILDING OWNER AT OCCUPANCY Residential Compliance Forms April 2005 ❑ ❑ Ye No NA No gaps Yes No N No voids over 3/a in. deep or more than 10% of the batt surface area. ❑ ❑ Yes No NA Insulation in contact with the air - barrier 1:1 ❑ Yes No NA Recessed light fixtures covered ❑ ❑ ❑ Net free- ventilation area maintained at eave vents Yes No NA ✓ ROOF /CEILING LOOSE -FILL ❑ ❑ Yes No NA Insulation uniformly covers the entire ceiling (or roof) area from the outside of all exterior walls. Or ❑ ❑ Yes No NA Baffles installed at eaves vents or soffit vents - maintain net free - ventilation area of eave vent ❑ z ❑ Yes No NA Attic access insulated ❑ ❑ Yes No NA Recessed light fixtures covered E�r ❑ ❑ Yes No NA Insulation at proper depth — insulation rulers visible and indicating proper depth and R -value ❑ ❑ ❑ Loose fill insulation meets or exceeds manufacturer's minimum weight and thickness requirements Yes No NA for the target R- value. Target R -value . Manufacturer's minimum required weight for the target R -value (pounds-per-square-foot). Manufacturer's minimum required thickness at time of installation . Manufacturer's minimum required settled thickness . Note: To receive compliance credit the HERS rater shall verb that the manufacturer's minimum weight and thickness has been achieved for the target R- value. CF -61? only) DECLARATION ✓ ❑ 1 hereby certify that the installation meets all applicable requirements as specified in the Insulation Installation Procedures. Installing Subcontractor (Co. Name) OR General Contractor (Co. Name) OR Owner Signature: Date: Copies to: BUILDING DEPARTMENT, HERS RATER (IF APPLICABLE), BUILDING OWNER AT OCCUPANCY Residential Compliance Forms April 2005 /l jti INSTALLATION CERTIFICATE (Page 12 of 12) CF -6R Site Address i Permit Number County Subdivision Lot Number Description of Insulation (Formerly IC -1 Form) 1'? 3 RAISED FLOOR Material Thickness (inches) SLAB FLOOR/PERIMETER Material Thickness (inches) Perimeter Insulation Depth (inches) EXTERIOR WALL Frame Type A. Cavity Insulation Material Thickness (inches) B . Exterior Foam Sheathing Material Thickness (inches) 4. FOUNDATION WALL Material Thickness (inches) G CEILING Brand Name Thermal Resistance (R- Value) Brand Name Thermal Resistance (R- Value) (J Brand Name Thermal Resistance (R- Value) J Brand Name Thermal Resistance (R- Value) Brand Name Thermal Resistance (R- Value) Batt or Blanket Type Brand Name Thickness (inches) Thermal Resistance (R- Value) Loose Fill Type Brand Contractor's min installed weight/ft' lb Minimum thickness inches Manufacturer's installed weight per square foot to achieve Thermal Resistance (R- Value) 6. ROOF Material Brand Name Thickness (inches) Thermal Resistance (R- Value) Declaration ✓ ❑ I hereby certify that the above insulation was installed in the building at the above location in conformance with the current Energy Efficiency Standards for residential buildings (Title 24, Part 6, California Code of Regulations) as indicated on the Certificate of Compliance, where applicable. Item #s (if applicable) Signature Date Installing Subcontractor (Co. Name) OR General Contractor (Co. Name) OR Owner OR Window Distributor Item #s Signature Date Installing Subcontractor (Co. Name) OR (if applicable) General Contractor (Co. Name) OR Owner OR Window Distributor Item #s Signature Date Installing Subcontractor (Co. Name) OR (if applicable) General Contractor (Co. Name) OR Owner OR Window Distributor Residential Compliance Forms April 2005 UTILITY RELEASE REQUEST FORM t:OMMUNO Y DE:VE_OPNIENT DEPARWENT • BOI, C ?t[' G DIVISION E ALBERT SALVADOR. P i . (� 8 0 81JI7_C,'.ING pF+- ICiAI. 10:300 fi]RRE AVENUF: • C:UPERTIN0 C -A 95014 -322 5 CUPERTINO f4{ 8) - 7!.3223 • nAX (408) 777 -3333 • :'iirirlin'� >" '.l ?'L(t!:'_'.:;': PURPOSE For resicierttial sinc_rli: faililly or duple\ Coristrut;tion, therec, are cases vdierc gas and electric utilities saric reclucsted to be rcleiised prior to dIC isstatnce of the certifivate of occu.panc,v. 1,7pon approval from the hmildin�g, inspector, the Ci €v of`Cuperuno is a11ov im,, h 3th. utilities to be rO as ed pricir (.o the final si,rt -klff of the buildi.og, itNs" ucriONS E. Download this f' s ...__l _ _.. _L_ �s ail,•: ni I a ,r �� f,,i�c I w � (,3!`111 al' )tlt T. Compiete the !firm and obtairt sivniatures front both the om ner of the property and the primary contractor, s. Brix, F- Mad. Mail car Aland defiver die oril!inal signed 1,orm .tfl, Cily of Cuperlino Building C)i �'isinn l un, Utility Release Requcs! Form 408 -777-3228 office 103110 Vorre Ave. 40 ' -7 77 -3333 fax Cilperlmos CA c_ . �J.il . i e___......- z....._..!_,.. of 4. ticiaec IC a Gjas Meter Release inspectitm (.'1403.) ane for i:lcctric Meter Release in.5pcction 0 4(4), f'Ica.sc note. ra Gas 'rest inspe.clioll (.006) is required phor to or aI the s;cme tulle of dic C:Jas, Mclin Release inspection. BUILDING .CNfs'C)Wl•jATION (Please complete the follc,,`ing infi:rmatio W APN I CI DG PERMIT #. Cy i t DA "LE f a J SITE ADDRESS' _� r 1 OVVNFR' NAM PHONE MAILING ADDRESS (if dif Brent fmm me address) ONTRA TDIR' ONE* C .Si i~1 - P. L FAX 1 ; .T .t GC?N7ACT 4!Z FAX #. # �a I request the City to reiease my utilities prior to r Dlaining a fmai impection aoprovai fcir the ouecfirg 1 fufly understand the ofzupanfs of tho bl; ding Cannot move into the residence until they receives ali o? the required Fina sign-oft and the City has Issued a of nrcupan or the? csiu,ttin._.__.. Owner � a �-- ✓`'t „i Enn[ ,. � T- .. � Contractor.., Print A i. D its. CUPERTINO TO: Brahmaji Potu Building Department CITY OF CUPERTINO 10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255 TELEPHONE: (408) 777 -3228 • FAX: (408) 777 -3333 FROM: City of Cupertino DATE: 2/4/2013 RE: Permit: 12070030 Address: 10466 S Tantau Ave We are issuing the above permit for construction of a new house with the following conditions: 1. The house will not be demolished until your demolition permit # has been issued. 2. If any work is started, permit # 12070030 be revoked and all work will be stopped. If the permit is revoked, new plans under the new codes, all new fees and new plan checks will be required. There are no exceptions. I understand and agree to the conditions above. )J( 9 / S2 (�-, � Date: Clremar• v n \, Date: / </ /2-, /Permit T A CUPERTINO OWNER - BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255 (408) 777 -3228 • FAX (408) 777 -3333 • buildirlO C7CUDertlno.org Dear Property Owner(s): An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified at: SITE ADDRESS v. APN -1 6P# /&' WiC OWNER NAME OWNER ADDRESS L vtr (,L t DESCRIPTION OF WORK: r, We are providing you with an Owner - Builder Acknowledgment and Information Verification Form to make you aware of your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner - Builder. We will not issue a building permit until you have read, initialed your understanding of each provision, signed, and returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION (DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information.) 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner - uild er' ' building permit that erroneously implies that the property owner is providing his or her own labor and material personally. I, as an Owner - Builder, may be held liable and subject to serious financial risk for any injuries sustained by an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an Owner - Builder and am aware of the limits of my insurance coverage for injuries to workers on my property. I understand building permits are not required to be signed by property owners unless they are responsible for e construction and are not hiring a licensed Contractor to assume this responsibility. I understand as an "Owner- Builder" I am the responsible party of record on the permit. I understand that I may p tect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. �. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer" under state and federal law. 16, 1 understand if I am considered an "employer" under state and federal law, I must register with the state and federal government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject me to serious financial risk. )� understand under California Contractors' State License Law, an Owner - Builder who builds single - family residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is performed under contract with a licensed general building Contractor. V18-1 understand as an Owner - Builder if I sell the property for which this permit is issued, I may be held liable for a y financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the workmanship or materials. OwnerBuilderFoi717 2010.doc revised 04114110 U19. I understand I may obtain more information regarding my obligations as an "employer" from the Internal evenue Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1- 800 - 321 -CSLB (2752) or www.cslb.ca.gov for more information about licensed contractors. t h10. 1 am aware of and consent to an Owner - Builder building permit applied for in my name, and understand that I e party legally and financially responsible for proposed construction activity at the site address listed above. nA 11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide -1-y —M applicable laws and requirements that govern Owner - Builders as well as employers. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the i formation I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If you contract with someone who does not have a license, the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be in civil court.. It is also important for you to understand that if an unlicensed Contractor or employee of that individual or firm is injured while working on your property, you may be held liable for damages. If you obtain a permit as Owner - Builder and wish to hire Contractors, you will be responsible for verifying whether or not those Contractors are properly licensed and the status of their workers' compensation insurance coverage. CONSTRUCTION LENDING AGENCY (DIRECTIONS: Please complete the following construction lending agency information.) hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec 3097 Civ.) Lender Name: Lender Address: Before a building permit can be issued, this form must be completed and signed by the property owner and returned to the agency responsible for issuing the permit. Note: A copy of the property owner's driver's license, form notarization, or other verification acceptable to thee' may be quired to be presented when the permit is issued to verify the property owner's si na e. Property Owner's Signature: Date: 2- 1 --------------- -- ---- --- ----- ---------- --- ----- --------- ------------ ----- -------- ----------- ---- ---------- ------------ ----- ------ ------------ (NOTE: The following Authorization Form is required to be completed by the property owner only when designating an agent of the property owner to apply for a construction permit for the Owner - Builder). AU "fHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize the following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an Owner - Builder Permit for my project. Scope of Construction Project (or Description of Work): Project Location or Address: Name of Authorized Agent: Address of Authorized Agent: Tel No declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above information and certify its accuracy. Note: A copy of the property owner's driver's license, form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's signature. Property Owner's Signature: Date: O)i-nerBuilderForrrt 2010.doc revised 04114110 OFFICE OF COMMUNITY DEVELOPMENT 01 CITY HALL 10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255 C U P E RT I N O (408) 777 -3308 • FAX (408) 777 -3333 - planning a()cupertino.orq March 26, 2012 F11L 19 Kiranmayi Potu --n77 10466 S Tantau Ave. Cupertino, CA 95014 e5 SUBJECT: RESIDENTIAL DESIGN REVIEW AND MINOR RESIDENTIAL PERMIT ACTION LETTER - Applications R- 2012 -03 and RM- 2012 -02: This letter confirms the decision of the Director of Community Development, given on March 23, 2012; approving a Residential Design Review for a new 3,430 square foot two -story single family residence and a Minor Residential Permit to allow a second floor deck and a portion of the new residence to encroach approximately five (5) feet into the required rear yard setback located at 10466 S. Tantau Avenue, with the following conditions: 1. APPROVED PROTECT This approval is based on a plan set entitled, "New 2 Story Single Family Residence, Owner: Mr. & Mrs. Potu, 10466 Tantau Ave, Cupertino, CA 95014;' drawn by Augustine Designs; consisting of 9 sheets labeled 1 though 7, and S1 dated September 19, 2011; except as may be amended by conditions in this resolution. 2. ACCURACY OF THE PROTECT PLANS The applicant/ property owner is responsible to verify all pertinent property data including but not limited to property boundary locations, building setbacks, property size, building square footage, any relevant easements and /or construction records. Any misrepresentation of any property data may invalidate this approval and may require additional review. 3. PRIVACY PLANTING The final privacy - planting plan shall be reviewed and approved by the Planning Division prior to issuance of building permits. If existing tree(s) is used for privacy screening, a letter from a certified arborist shall be submitted confirming that the tree(s) is in good condition and is appropriate privacy protection in any season. 4. PRIVACY PROTECTION COVENANT The property .owner shall record a covenant on this property to inform future property owners of the privacy protection measures and tree protection requirements consistent with the R -1 Ordinance, for all windows with views into neighboring yards and a sill height that is 5 feet or less from the second story finished floor. The precise language will be subject to approval by the Director of Community Development. Proof of recordation must be submitted to the Community Development Department prior to final occupancy of the residence. PURPOSE: 2010 CALGREEN CHECKLIST — MANDATORY ITEMS COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION_,„ ALBERT SALVADOR, FI:E., C.B.O., BUILDING OFFICIAL 10300 TORRE AVENUE I "4-3 jUL `Li u- (408) 777 -3228 • FAX (4) The 2010 CalGreen Code applies to all newly constructed hotels, motels, lodging houses, dwellings, dormitories, condominiums, shelters, congregate residences, employee housing, factory-built housing and other types of swellings with sleeping accommodations and new accessory buildings associated with such uses. Existing site and landscaping improvements that are not otherwise disturbed are not subject to the requirements of CALGreen. Project Name: Project Address: f 1 ct, �, c U.; ) ` , m .,� ( - �� S c ( l__. Project Description: _k4my, ; c } 1 7 GR�.�ccavPI, Instructions: �J 1. The Owner or the Owner's agent shall employ a licensed professional experienced with the 2010 California Green Building Standards Codes to verify and assure that all required work described herein is properly planned and implemented in the project. 2. The licensed professional, in collaboration with the owner and the design professional shall initial Column 2 of this checklist, sign and date Section 1 - Design Verification at the end of this checklist and have the checklist printed on the approved plans for the project. 3. Prior to final inspection by the Building Department, the licensed professional shall complete Column 3 and sign and date Section 2 - Implementation Verification at the end of this checklist and submit the completed form to the Building Inspector. Column 2 Column 3 MANDATORY FEATURE OR MEASURE Project Verification Re uirements A4.1 PLANNING AND DESIGN Planning and Design - Site Preservation 4.104.1 A site plan and inventory of the site is developed and used to minimize site disturbance in order preserve desirable existing natural resources and ❑X ❑ minimize future adverse effects on the proposed structure. Planning and Design - Site Development 4.106.2 A plan is developed and implemented to manage storm water ❑ ❑ drainage during construction. 4.106.3 The site shall be planned and developed to keep surface water away from buildings. Construction plans shall indicate how site grading or a drainage X❑ ❑ system will manage all surface water flows. Page 1 of 5 CalGreen 2010doc revised 02114111 4.201.1 Low -rise residential buildings shall meet or exceed the minimum ❑ El design required by the California Energy Standards. A4.3 WATER AND f Indoor Water Use 4.303.1 Indoor water use shall be reduced by at least 20 percent using one of the follow methods. Water saving fixtures or flow restrictors shall be used per Table 4.303.2. )121 ❑ ❑ A 20 percent reduction in baseline water use shall be demonstrated per 7/01/2011 Table 4.303.1. 4.303.2 When using the calculation method specified in Section 4.303.1, multiple showerheads shall not exceed maximum flow rates. ❑ 7/01/2011 4.303.3 Plumbing fixtures (water closets and urinals) and fittings (faucets and showerheads) shall comply with specified performance requirements. ❑ 7/01/2011 Outdoor Water Use 4.304.1 Automatic irrigation systems installed at the time of final inspection ❑ ❑ shall be weather- based. A4.4 I . • 1 CONSERVATION 4 , RESOURCE Enhanced Durability and Reduced Maintenance 4.406.1 Joints and openings. Annular spaces around pipes, electric cables, conduits, or other openings in plates at exterior walls shall be protected ❑ El the passage of rodents by closing such openings with cement mortar, concrete masonry or similar method acceptable to the enforcing agency. Construction Waste Reduction, Disposal and Recycling 4.408.2 Where a local jurisdiction does not have a construction and demolition 0 ❑ waste management ordinance, a construction waste management plan shall be submitted for approval to the enforcing agency. Building Maintenance and Operation 4.410.1 An operation and maintenance manual shall be provided to the ❑ ❑ building occupant or owner. Page 2 of 5 CalGreen 2010.doc revised 02114111 A4.5 -O Fireplaces 4.503.1 Install only a direct -vent sealed - combustion gas or sealed wood- ❑ ❑ burning fireplace, or a sealed woodstove. Pollutant Control 4.504.1 Duct openings and other related air distribution component openings ❑ ❑ shall be covered during construction. 4.504.2.1 Adhesives, sealants and caulks shall be compliant with VOC and ❑ ❑ other toxic compound limits. 4.504.2.2 Paints, stains and other coatings shall be compliant with VOC limits. 0 ❑ 4.504.2.3 Aerosol paints and other coatings shall be compliant with product ❑X ❑ weighted MIR Limits for ROC and other toxic compounds. 4.504.2.4 Documentation shall be provided to verify that compliant VOC limit ❑ El materials have been used. 4.504.3 Carpet and carpet systems shall be compliant with VOC limits. ❑X ❑ 4.504.4 Fifty (50) percent of floor area receiving resilient flooring shall comply with the VOC- emission limits defined in the Collaborative for High Performance ❑ ❑ Schools (CHPS) Low - emitting Materials List or be certified under the Resilient Floor Covering Institute (RCFI) FloorScore program. 4.504.5 Particleboard, medium density fiberboard (MDF), and hardwood ❑ plywood used in interior finish systems shall comply with low formaldehyde ❑X emission standards. Interior Moisture Control 4.505.2 Vapor retarder and capillary break is installed at slab on grade ❑%� ❑ foundations. 4.505.3 Moisture content of building materials used in wall and floor framing is ❑ ❑ checked before enclosure. Page 3 of CalCreen 2010. doe revised 02114111 Indoor Air Quality and Exhaust 4.506.1 Exhaust fans which terminate outside the building are provided in ❑ every bathroom. Environmental Comfort 4.507.1 Whole house exhaust fans shall have insulated louvers or covers which close when the fan is off. Covers or louvers shall have a minimum ❑X ❑ insulation value of R-4.2. 4.507.2. Duct systems are sized and designed and equipment is selected using the following methods: 1. Establish heat loss and heat gain values according to ACCA Manual J or ❑ ❑ equivalent. 2. Size duct systems according to ACCA 29 -D (Manual D) or equivalent. 3. Select heating and cooling equipment according to ACCA 36 -S (Manual S) or equivalent. INSTALLER 6 SPECIAL INSPECTOR Qualifications 702.1 HVAC system installers are trained and certified in the proper installation © ❑ of HVAC systems. 702.2 The Licensed Professional responsible to verify CALGreen compliance is qualified and able to demonstrate competence in the discipline they inspect ❑X ❑ and verify. Verifications 703.1 Verification of compliance with CALGreen may include construction documents, plans, specifications builder or installer certification, inspection reports, or other methods acceptable to the enforcing agency which show ❑ substantial conformance. Implementation verification shall be submitted to the Building Department after implementation of all required measures and prior to final inspection approval. Page 4 of 5 CalGreen 2010.dop revised 02114111 CALGREEN SIGNATURE DECLARATIONS Project Name: -Ne 1� _S1.4 = )An le L • A +` i. a ice , X A Project Address: Project Description: V_ vllw� 4,E. SECTION 1 — DESIGN VERIFICATION g. Complete all lines of Section 1 — "Design Verification" and submit the completed checklist (Columns 1 and 2) with the plans and building permit application to the Building Department. The owner and design professional responsible for compliance with CalGreen Standards have revised the plans and certify that the items checked above are hereby incorporated into the project plans and will be implemented into the project in accord nce with the requirements set forth in the 2010 California Green Building Standards Code as adopted by the c i f Cupertino. L� Owner's Signature Date 1 RA N I Owner's Design Professional's Design Professional's Name (Please Print) 01 1 Signature of License Professional responsible for CalGreen compliance Name of License Professional responsible for CalGreen compliance (Please Print) Email Address for License Professional responsible for CalGreen compliance SECTION 2 — IMPLEMENTATION VERIFICATION Date Date Phone W1 Complete, sign and submit the competed checklist, including column 3, together with all original signatures on Section 2 to the Building Department prior to Building Department final inspection. I have inspected the work and have received sufficient documentation to verify and certify that the project identified above was constructed in accordance with this Green Building Checklist and in accordance with the requirements of the 2010 California Green Building Standards Code as adopted by the City of Cupertino. Signature of License Professional responsible for CalGreen compliance Date Name of License Professional responsible for CalGreen compliance (Please Print) Phone for reen compliance Page 5 of 5 CalGreen 2010.doc revised 02114111 BUILDING ENERGY ANALYSIS REPORT PROJECT: Potu Residence 10466 Tantau Avenue Cupertino, CA 95014 Project Designer: Augustine Designs 3033 Moorpark Ave, #7 San Jose, CA 95128 408 - 294 -7060 Report Prepared by: Nicholas L Bignardi R08 -11 -2009 FRI Energy Consultants, LLC 21 N. Harrison Ave Suite 210 Campbell, CA 95008 408 - 866 -1620 Job Number: 0120324 Date: 7/2/2012 The EnergyPro computer program has been used to perform the calculations summarized in this compliance report. This program has approval and is authorized by the California Energy Commission for use with both the Residential and Nonresidential 2008 Building Energy Efficiency Standards. This program developed by EnergySoft, LLC — www.energysoft.com. EnergyPro 5.1 by EnergySoft User Number. 1315 RunCode: 2012- 07- 02T10:44:00 ID. 0120324 1 EQUIPMENT LIST AND INSULATION PLACEMENT NOTE NEW HOME FOR POTU RESIDENCE 10466 TANTAU AVENUE CUPERTINO, CA 95014 #0120324 NOTE: MINIMUM HEATING AND COOLING LOAD CALCULATIONS ARE GENERATED BY THE COMPUTER PROGRAM. THERE ARE OTHER DESIGN FACTORS THAT MUST BE CONSIDERED, DUCT FLOW, COIL SIZING, OVERSIZING SAFETY MARGIN, ETC. IT IS THE RESPONSIBILITY OF THE MECHANICAL CONTRACTOR OR WHOEVER DESIGNS AND INSTALLS THE HEATING AND COOLING SYSTEM TO MAKE THE FINAL DECISION ABOUT THE SIZE OF THE EQUIPMENT TO BE INSTALLED. THE HVAC EQUIPMENT USED MUST MEET THE EFFICIENCIES SHOWN IN THE TITLE 24 CALCULATIONS. THESE ARE AS FOLLOWS: HEATING: NEW FURNACE(S) MUST HAVE AN AFUE OF .95 OR BETTER. FURNACE(S) MUST BE ABLE TO HANDLE THE HEATING LOAD. AIR CONDITIONING: AIR - CONDITIONING TO BE INSTALLED MUST HAVE A MINIMUM SEER OF 13. SETBACK THERMOSTAT: A SETBACK THERMOSTAT IS REQUIRED FOR EACH NEW FURNACE. WHOLE HOUSE VENTILATION REQUIREMENTS: NOTE: THIS IS A REQUIREMENT FOR ALL NEW BUILDINGS AND ANY ADDITION THAT IS LARGER THAN 1000 FT SQUARED. CFM equation: Ventilation Rate (cfm) = (CFA /100) +7 .5 x (# of bedrooms + 1) Equation given above can be used or Table 4 -7 of the 2008 Residential Manual may be used to determine the required Ventilation. HOT WATER HEATER: WE SHOW 2 TANKLESS WATER HEATERS IN OUR CALCULATIONS. THE FIRST 5 FT. OF PIPES FROM THE STORAGE TANK MUST BE INSULATED WITH ONE INCH OF INSULATION FOR BOTH HOT AND COLD WATER PIPES. TABLE 150 -B PIPE INSULATION MINIMUM THICKNESS REQUIREMENTS PIPE DIAMETER Less than or Equal to Greater than 2 inches 2 inches INSULATION THICKNESS REQUIRED (in SYSTEM inches) Domestic hot water (above 105T) 1.0 1.5 Hydronic heating supply lines (above 200 °F 1.0 2.0 to 250 °F) 1 Hydronic heating supply lines (105 °F to 1.0 1.5 200 °F) Cooling system refrigerant suction, chilled 0.75 1.0 water and brine lines 1 Steam hydronic heating systems or hot water systems with pressure above 15 psi shall meet the requirements of TABLE 123 -A. FAUCETS AND SHOWERHEADS: SHOWERHEADS AND FAUCETS MUST BE ON THE CEC APPROVAL LISTING IN ORDER TO BE INSTALLED. THIS CAN BE CHECKED THROUGH THE BUILDING DEPARTMENT ISSUING THE BUILDING PERMIT, THE CALIFORNIA ENERGY COMMISSION 916- 654 -4080, OR BY CALLING OUR OFFICE 408 - 866 -1620. INSULATION PLACEMENT: INSULATION TO BE INSTALLED MUST MEET CEC QUALITY STANDARDS. FOR GLAZING U- FACTORS AND SHGC VALUES REFER TO THE CF -1R 02 THE REPORT. NOTE: ALL R- VALUES AND U- VALUES LISTED ARE MINIMUM VALUES AND CAN BE EXCEEDED. LIGHTING: PERMANENTLY INSTALLED LUMINARIES LOCATED IN BATHROOMS, GARAGES, LAUNDRY ROOMS, AND UTILITY ROOMS SHALL BE HIGH EFFICACY LUMINARIES OR LOW EFFICACY CONTROLLED BY A MANUAL ON AUTOMATIC OFF OCCUPANT SENSOR(S) CERTIFIED TO COMPLY WITH SECTION 119(D) PERMANENTLY INSTALLED LUMINARIES LOCATED IN ROOMS OTHER THAN IN KITCHENS, BATHROOMS, GARAGES, LAUNDRY ROOMS, AND UTILITY ROOMS SHALL BE HIGH EFFICACY LUMINARIES (EXCEPT CLOSETS LESS THAN 70 FT) OR LOW EFFICACY BULBS CONTROLLED BY A DIMMER SWITCH OR BY AN MANUAL ON AUTOMATIC OFF OCCUPANT SENSOR THAT COMPLIES WITH SECTION 119(d). HIGH EFFICACY LUMINARIES OTHER LAMPS AS OUTLINED IN TABLE 150 SOCKET (E24/E26). BALLAST FOR HAVE AN OUTPUT FREQUENCY NO LESS T THAN OUTDOOR HID: CONTAIN ONLY HIGH EFFICACY -C, AND DO NOT CONTAIN A MEDIUM SCREW BASE LAMPS WATTS OR GREATER ARE ELECTRONIC AND 0 LUMINARIES THAT ARE RECESSED INTO INSULATED CEILINGS MUST BE APPROVED FOR ZERO CLEARANCE INSULATION COVER (IC) AND ARE CERTIFIED TO ASTM E283 AND LABELED AS AIR TIGHT (AT) TO LESS THAN 2.0 CFM AT 75 PASCALS Lamp Power Rating for Non -LED Lighting Minimum Lamp Efficacy for Non -LED (see Note 1), or System Power Rating for LED Lighting, or Minimum System Efficacy for Lighting (see Notes 2, 3, and 4) LED Lightin 5 watts or less 30 lumens per watt over 5 watts to 15 watts 40 lumens per watt over 15 watts to 40 watts 50 lumens per watt over 40 watts 60 lumens per watt Notes: 1. Determine minimum lamp efficacy category for lighting systems which are not LED using the initial rated lumens divided by the rated watts of the lamp (not including the ballast). 2. To qualify as high efficacy, an LED luminaire shall meet the minimum system efficacy requirements in Table 150 -C when determined according to Reference Joint Appendix JA8, and be certified to comply with Section 119(m), and input power shall be determined according to Section 130(d)5. 3. For a Hybrid LED Luminaire to qualify as a high efficacy luminaire, all lighting systems in the luminaire shall qualify as high efficacy according to Section 150(k)1, and the LED Light Engine with Integral Heat Sink shall comply with Note 4, below. 4. To qualify as high efficacy, an LED Light Engine with Integral Heat Sink shall meet the minimum system efficacy requirements in Table 150 -C when determined according to Reference Joint Appendix JA8, shall be certified to comply with Section I I9(m), and input power shall be determined according to Section 130(d)5. WHEN IN DOUBT ABOUT MEETING THIS REQUIREMENT CALL FRI ENERGY CONSULTANTS, 408 - 866 -1620. ALL FLUORESCENT BALLAST MUST BE APPROVED BY THE CEC, THIS CAN BE CHECKED THROUGH THE BUILDING DEPARTMENT ISSUING THE BUILDING PERMIT, THE CALIFORNIA ENERGY COMMISSION 916- 324 -3376, OR BY CALLING OUR OFFICE 408 - 866 -1620. ALL REFRIGERATORS, REFRIGERATOR- FREEZERS AND FREEZERS MUST BE ON THE CEC APPROVAL LIST THIS CAN BE CHECKED THROUGH THE BUILDING DEPARTMENT ISSUING THE BUILDING PERMIT, THE CALIFORNIA ENERGY COMMISSION 916- 324 -3376, OR BY CALLING OUR OFFICE 408 - 866 -1620. NEW HOME FOR #0120324 POTU RESIDENCE 10466 TANTAU AVENUE CUPERTINO, CA 95014 THESE ARE MINIMUM INSULATION LEVELS FOR THE ADDITION /ALTERATION ONLY. APPLIC. R- VALUE. INSUL. TYPE 1. TYPICAL FLAT CEILING TYP R -30 INSULATION, BATT OR RIGID 2. VAULTED ROOF W /ATTIC N/A INSULATION, BATT OR RIGID 3. VAULTED ROOF NO ATTIC N/A INSULATION, BATT OR RIGID 4. EXTERIOR WALL TYP R -13 INSULATION, BATT OR RIGID S. SEPARATION WALL N/A INSULATION, BATT OR RIGID 6. WALL BACKING INTO ATTIC N/A INSULATION, BATT OR RIGID 7. CRAWL SPACE FLOOR TYP R -19 INSULATION, BATT OR RIGID 8. FLOOR ABOVE GARAGE N/A INSULATION, BATT OR RIGID 9. SLAB EDGE INSULATION' N/A SEE NOTE BELOW 10. BUILT UP ROOF N/A 11. CANTILEVERED FLOOR N/A INSULATION BATT OR RIGID U -VALUE SHGC 12. GLAZING TYP 0.40 0.40 DOUBLE NON -METAL LOW -E FRENCH DOORS TYP 0.40 0.40 DOUBLE NON -METAL LOW -E SLIDING GLASS DOORS N/A DOUBLE NON -METAL OR BETTER 13. SKYLIGHTS N/A DOUBLE NON- METAL,OR BETTER 14. HEATING & COOLING DUCTS MINIMUM INSL. R -VALUE 6.0 ' THE MINIMUM DEPTH OF CONCRETE -SLAB FLOOR PERIMETER INSULATION SHALL BE 16 INCHES OR THE DEPTH OF THE FOOTING OF THE BUILDING, WHICHEVER IS LESS. NOTE: THIS CROSS SECTION IS USED ONLY FOR DIAGRAMMATIC PURPOSES AND IS NOT A TRUE CROSS SECTION OF THIS PROJECT. I TABLE OF CONTENTS I Cover Page 1 Table of Contents 2 Form CF -1 R Certificate of Compliance 3 Form MF -1 R Mandatory Measures Summary 9 HVAC System Heating and Cooling Loads Summary 12 EnergyPro 5.1 by EnergySoft Job Number: ID: 0120324 —_—User Number: 1315 _ PERFORMANCE CERTIFICATE: Residential Part 1 of 5 CF -1 R Project Name Potu Residence Building Type m Single Family ❑ Addition Alone ❑ Multi Family ❑ Existing+ Addition /Alteration Date 71212092 Project Address 10466 Tantau Avenue Cupertino California Energy Climate Zone CA Climate Zone 04 Total Cond. Floor Area 3,430 Addition n/a # of Stories 2 FIELD INSPECTION ENERGY CHECKLIST ❑ Yes ❑ No HERS Measures -- If Yes, A CF -4R must be provided per Part 2 of 5 of this form. ❑ Yes ❑ No Special Features -- If Yes, see Part 2 of 5 of this form for details. INSULATION Construction Type Area Special Cavity (fe) Features see Part 2 of 5 Status Floor Wood Framed w /Crawl Space R -19 1,994 New Wall Wood Framed R -13 2,695 New Door Opaque Door Roof Wood Framed Attic None 18 New R -30 1,994 Radiant Barrier New FENESTRATION U- Orientation Area(ft) Factor Exterior SHGC Overhang Sidefins Shades Status Front (NW 170.0 0.400 0.40 none none Bug Screen New Right (SW 75.5 0.400 0.40 none none Bug Screen New Rear (SE) 115.8 0.400 0.40 none none Bug Screen New Rear (SE) 120.0 0.400 0.40 none none Bug Screen New Left (NE) 53.4 0.400 0.40 none none Bug Screen New Left (NE) 172.0 0.400 0.40 none none Bug Screen New HVAC SYSTEMS Qty. Heating Min. Eff Cooling Min. Eff Thermostat Status 1 Central Furnace 95% AFUE Split Air Conditioner 13.0 SEER Setback 1 Central Furnace 95% AFUE Split Air Conditioner 13.0 SEER Setback New New HVAC DISTRIBUTION Location Heating Duct Cooling Duct Location R -Value Status HVAC System Ducted Ducted Attic, Ceiling Ins, vented 6.0 New HVAC System Ducted Ducted Attic, Ceiling Ins, vented 6.0 New WATER HEATING Qty. Type Gallons Min. Eff Distribution Status 2 Instant Gas 0 0.93 All Pipes Ins New EnergylDro5.1 by EnergySoft User Number: 1315 RunCode: 2012- 07- 02T10:44 :00 ID: 0120324 Page 3 of 13 PERFORMANCE CERTIFICATE: Residential (Part 2 of 5) CF -1 R Project Name Potu Residence Building Type ® Single Family 11 Addition Alone 11 Multi Family ❑ Existing+ Addition /Alteration Date 71212012 SPECIAL FEATURES INSPECTION CHECKLIST The enforcement agency should pay special attention to the items specified in this checklist. These items require special written justification and documentation, and special verification to be used with the performance approach. The enforcement agency determines the adequacy of the justification, and may reject a building or design that otherwise complies based on the adequacy of the special justification and documentation submitted. The Roof R -30 Roof Attic w /Radiant Barrier includes credit for a Radiant Barrier that is Continuous meeting eligibility and installation criteria as specified in Residential Appendix RA4.2 2. HERS REQUIRED VERIFICATION Items in this section require field testing and /or verification by a certified HERS Rater. The inspector must receive a completed CF -4R form for each of the measures listed below for final to be given. EnenqyPro 5.1 by EnerqySoft User Number: 1315 RunCode: 2012- 07 -02T10 :44:00 ID.-0120324 Page 4 of 13 PERFORMANCE CERTIFICATE: Residential (Part 3 of 5) CF -1 R Project Name Building Type m Single Family ❑ Addition Alone Date Potu Residence ❑ Multi Family ❑ Existing+ Addition /Alteration 71212012 ANNUAL ENERGY USE SUMMARY Standard Proposed Margin TDV (kBtu/ft2- r) Space Heating 20.54 18.79 1.75 Space Cooling 6.61 8.30 -1.69 Fans 4.47 5.13 -0.66 Domestic Hot Water 11.52 7,58 3.94 Pumps 0.00 0.00 0,00 Totals 43.14 39.81 3.33 Percent Better Than Standard: 7.7 BUILDING COMPLIES - NO HERS VERIFICATION REQUIRED Fenestration Building Front Orientation: (NM 315 deg Ext. Walls /Roof Wall Area Area Number of Dwelling Units: 1.00 (NM 649 170 Fuel Available at Site: Natural Gas (NE) 915 225 Raised Floor Area: 1,994 (SE) 1,074 236 Slab on Grade Area: 0 (StM 782 76 Average Ceiling Height: 9,1 Root 1,994 0 Fenestration Average U- Factor: 0.40 TOTAL: 707 Average SHGC: 0.40 Fenestration /CFA Ratio: 20.6% REMARKS STATEMENT OF COMPLIANCE This certificate of compliance lists the building features and specifications needed to comply with Title 24, Parts 1 the Administrative Regulations and Part 6 the Efficiency Standards of the California Code of Regulations. The documentation author hereby certifies that the documentation is accurate and complete. Documentation Author Company FRI Energy Consultants, LLC `�� t Address 21 N. Harrison Ave Suite 210 Name Nicholas L Bignardi R08 -11 -2009 Cit /State /Zip Campbell, CA 95008 Phone 408- 866 -1620 Signed _ Date The individual with overall design responsibility hereby certifies that the proposed building design represented in this set of construction documents is consistent with the other compliance forms and worksheets, with the specifications, and with any other calculations submitted with this permit application, and recognizes that compliance using duct design, duct sealing, verification of refrigerant charge, insulation installation quality, and building envelope sealing require installer testing and certification and field verification by an approved HERS rater. Designer or Owner (per Business & Professions Code) Company Augustine Designs 3033 Moorpark Ave, #7 Richard Augustine Address � Name 9 City /State /Zip San Jose, CA 95128 Phone 408 - 294 -7060 Signed icense # ate EnerqyPro 5.1 by EnerqySoft User Number: 1315 RunCode: 2012- 07- 02T10:44:00 ID: 0120324 Page 5 of 13 CERTIFICATE OF COMPLIANCE: Residential (Part 4 of 5) CF -1 R Project Name Potu Residence Building Type 0 Single Family ❑ Addition Alone ❑ Multi Family ❑ Existing+ Addition /Alteration Date 71212012 OPAQUE SURFACE DETAILS Surface Type Area U- Factor Insulation Azm Tilt Status Joint Appendix 4 Location /Comments Cavity Exterior Tra-m-eTint-e-riorf Frame Floor 1,877 0.037 R -19 0 180 New 4.4.1 -A4 1st Floor Wall 28 0.102 R -13 180 90 New 4.3.1 -A3 1st Floor Wall 339 0.102 R -13 315 90 New 4.3.143 1st Floor Door 18 0.500 None 315 90 New 4.5.1 -A4 1st Floor Wall 384 0.102 R -13 225 90 New 4.3.1 -A3 1st Floor Wall 531 0.102 R -13 135 90 New 4.3.1 -A3 1st Floor Wall 495 0.102 R -13 45 90 New 4.3.1 -A3 1st Floor Roof 441 0.031 R -30 90 18 New 4.2.1 -A20 1st Floor Floor 117 0.037 R -19 0 180 New 4.4.1 -A4 2nd Floor Wall 122 0.102 R -13 315 90 New 4.3.1 -A3 2nd Floor Wall 322 0.102 R -13 225 90 1 New 4.3.1 -A3 2nd Floor Wall 279 0.102 R -13 135 90 New 4.3.1 -A3 2nd Floor Wail 195 0,102 R -13 45 90 New 4.3.1 -A3 2nd Floor Roof 1,553 0.031 R -30 180 18 New 4.2.1 -A20 2nd Floor FENESTRATION SURFACE DETAILS ID Type Area LI- Factor SHGC2 Azm Status Glazing Type Location/Comments 1 Window 36.0 0.400 NFRC 0.40 NFRC 315 New Double Non Metal Clear Low -E 1 st Floor 2 Window 36.0 0.400 NFRC 0.40 NFRC 315 New Double Non Metal Clear Low -E 1st Floor 3 Window 360 0.400 NFRC 0.40 NFRC 315 New Double Non Metal Clear Low -E 1 st Floor 4 Window 27.5 0.400 NFRC 0.40 NFRC 225 New Double Non Metal Clear Low -E 1st Floor 5 Window 17.8 0.400 NFRC 0.40 NFRC 135 New Double Non Metal Clear Door L 1st Floor 6 Window 33.4 0.4001 NFRC 0.40 NFRC 135 New Double Non Metal Clear Door L 1st Floor 7 Window 48.0 0.400 NFRC 0.40 NFRC 135 New Double Non Metal Clear Low -E 1st Floor 8 Window 28.0 0.400 NFRC 0.40 NFRC 135 New Double Non Metal Clear Low -E 1st Floor 9 Window 24.0 0.400 NFRC 0.40 NFRC 135 New Double Non Metal Clear Low -E 1st Floor 10 Window 53.4 0.400 NFRC 0.40 NFRC 45 New Double Non Metal Clear Door L 1st Floor 11 Window 32.0 0.400 NFRC 0.40 NFRC 45 New Double Non Metal Clear Low -E 1 st Floor 12 Window 60.0 0.400 NFRC 0.40 NFRC 45 New Double Non Metal Clear Low -E 1 st Floor 13 Window 36.0 0.400 NFRC 0.40 NFRC 45 New Double Non Meta) Clear Low -E 1st Floor 14 Window 24.0 0.400 NFRC 0.40 NFRC 45 New Double Non Metal Clear Low -E 1st Floor 15 Window 14.0 0.400 NFRC 0.40 NFRC 315 New Double Non Metal Clear Low -E 2nd Floor 16 Window 24.0 0.400 NFRC 0.40 NFRC 315 New Double Non Metal Clear Low -E 12nd Floor (1) U- Factor Type: 116 -A = Default Table from Standards, NFRC = Labeled Value 2 SHGC Type: 116 -B = Default Table from Standards, NFRC = Labeled Value EXTERIOR SHADING DETAILS ID Exterior Shade T e SHGC Window Ove hanq Left Fin Ri ht Fin H t Wd Len H t LExt RExt Dist Len H t Dist Len H t 1 Bug Screen 0.76 2 Bug Screen 0.76 3 Bug Screen 0.76 4 Bug Screen 0.76 5 Bug Screen 0.76 6 Bug Screen 0.76 7 Bug Screen 0.76 8 Bug Screen 0.76 9 Bug Screen 0.76 10 Bug Screen 0.76 11 Bug Screen 0.76 12 Bug Screen 0.76 13 Bug Screen 0.76 14 Bug Screen 0.76 15 Bug Screen 0.76 16 Bug Screen 0.76 EnergyPro 5.1 by EnergySoft User Number: 1315 RunCode: 2012 -07- 02710:44:00 ID: 0120324 Pa e 6 of 13 CERTIFICATE OF COMPLIANCE: Residential (Part 4 of 5) CF -1 R Project Name Potu Residence Building Type m Single Family ❑ Addition Alone ❑ Multi Family ❑ Existing+ Addition /Alteration Date 71212012 OPAQUE SURFACE DETAILS Surface —Type Area U- Factor Insulation Azm Tilt Status Joint Appendix 4 Location /Comments Cavit Exterior Frame Interior Frame FENESTRATION SURFACE DETAILS ID Type Area U- Factor SHGC Azm Status Glazing Type Location /Comments 17 Window 24.0 0.400 NFRC 0.40 NFRC 315 New Double Non Metal Clear Low -E 2nd Floor 18 Window 20.0 0.400 NFRC 0.40 NFRC 225 New Double Non Metal Clear Low -E 2nd Floor 19 Window 28.0 0.400 NFRC 0.40 NFRC 225 New Double Non Metal Clear Low -E 2nd Floor 20 Window 15.6 0.400 NFRC 0.40 NFRC 135 New Double Non Metal Clear Door L 2nd Floor 21 Window 15.6 0.400 NFRC 0.40 NFRC 135 New Double Non Metal Clear Door L 2nd Floor 22 Window 33.4 0.400 NFRC 0.40 NFRC 135 New Double Non Metal Clear Door L 2nd Floor 23 Window 20.0 0.400 NFRC 0.40 NFRC 135 New Double Non Metal Clear Low -E 2nd Floor 24 Window 20.0 0.400 NFRC 0.40 NFRC 45 New Double Non Metal Clear Low -E 2nd Floor (1) U- Factor Type: 116 -A = Default Table from Standards, NFRC = Labeled Value 2 SHGC Type: 116 -B = Default Table from Standards, NFRC = Labeled Value EXTERIOR SHADING DETAILS ID Exterior Shade Type SHGC Window Ove hang Left Fin Right Fin H t Wd Len H t LEA RExt Dist Len H t Dist Len H t 17 Bug Screen 0.76 18 Bug Screen 0.76 19 Bug Screen 0.76 20 Bug Screen 0.76 21 Bug Screen 0.76 22 Bug Screen 0.76 23 Bug Screen 0.76 24 Bug Screen 0.76 EnergyPro 5.1 by EnergySoft User Number: 1315 RunCode: 2012 -07- 02710:44:00 ID: 0120324 Pa e 7 of 13 CERTIFICATE OF COMPLIANCE: Residential (Part 5 of 5) CF -1 R Project Name Potu Residence Building Type © Single Family ❑ Addition Alone ❑ Multi Family ❑ Existing+ Addition /Alteration Date 71212012 BUILDING ZONE INFORMATION System Name Zone Name Floor Area ft New Existing Altered Removed Volume Year Built HVAC System 1 st Floor 1,877 18, 770 HVAC System 2nd Floor 1,553 12,424 Totals 1 3,4301 01 0 0 HVAC SYSTEMS System Name Qty. Heatin Type Min. Eff. Cooling T e Min. Eff. Thermostat T e Status HVAC System 1 Central Furnace 95% AFUE Split Air Conditioner 13.0 SEER Setback New HVAC System 1 Central Furnace 95% AFUE Split Air Conditioner 13.0 SEER Setback New HVAC DISTRIBUTION System Name Heating Cooling Duct Location Duct R -Value Ducts Tested? Status HVAC System Ducted Ducted Attic, Ceiling Ins, vented 6.0 ❑ New HVAC System Ducted Ducted Attic, Ceiling Ins, vented 6.0 ❑ New WATER HEATING SYSTEMS S stem Name Qty, Type Distribution Rated Input Btuh Tank Cap. al Energy Factor or RE Standby Loss or Pilot Ext. Tank Insul. R- Value Status Takagi T -H2 -DV 2 Instant Gas All Pipes Ins 199,000 0 0.93 n/a n/a New MULTI - FAMILY WATER HEATING DETAILS HYDRONIC HEATING SYSTEM PIPING Control Hot Water Piping Length (ft) o v=i Q System Name Pipe Length Pipe Diameter Insul. Thick. Otyl HP Plenum Outside Buried EnergyPro 5.1 by EnergySoft User Number: 1315 RunCode: 2012 -07- 02710:44:00 ID: 0120324 Pa e 8 of 13 MANDATORY MEASURES SUMMARY: Residential (Page 1 of 3 MF -1 R Project Name Potu Residence Date 71212012 NOTE: Low -rise residential buildings subject to the Standards must comply with all applicable mandatory measures listed, regardless of the compliance approach used. More stringent energy measures listed on the Certificate of Compliance (CF -1 R, CF -1 R -ADD, or CF- 1 R -ALT Form) shall supersede the items marked with an asterisk ( *) below. This Mandatory Measures Summary shall be incorporated into the permit documents, and the applicable features shall be considered by all parties as minimum component performance specifications whether they are shown elsewhere in the documents or in this summary. Submit all applicable sections of the MF -1 R Form with plans. Building Envelope Measures: 116(a)l: Doors and windows between conditioned and unconditioned spaces are manufactured to limit air leakage. §116(a)4: Fenestration products (except field- fabricated windows) have a label listing the certified U- Factor, certified Solar Heat Gain Coefficient SHGC , and infiltration that meets the requirements of 10 -111 (a) . 117: Exterior doors and windows are weather-stripped; all joints and penetrations are caulked and sealed. 118(a): Insulationspecified or installed meets Standards for Insulating Material. Indicate type and include on CF -6R Form. §118(i): The thermal emittance and solar reflectance values of the cool roofing material meets the requirements of §118(1) when the installation of a Cool Roof is specified on the CF -1 R Form. * §150(a): Minimum R -19 insulation in wood -frame ceiling or equivalent U- factor. 150(b): Loose fill insulation shall conform with manufacturer's installed design labeled R- Value. *§1 50(c): Minimum R -13 insulation in wood -frame wall orequivalent U- factor. *§1 50 d : Minimum R -13 insulation in raised wood -frame floor orequivalent U- factor. 150(f): Air retardin wrap is tested, labeled, and installed according to ASTM E1677- 95(2000) when specified on the CF -1 R Form. 150(g): Mandatory Vapor barrier installed in Climate Zones 14 or 16. §150(1): Water absorption rate for slab edge insulation material alone without facings is no greater than 0.3 %; water vapor permeance rate is no greater than 2.0 perm/inch and shall be protected from physical damage and UV light deterioration. Fireplaces, Decorative Gas Appliances and Gas Log Measures: 150(e)1 A: Masonry or factory-built fireplaces have a closable metal or glass door covering the entire opening of the firebox. _ §150(e)18: Masonry or factory-built fireplaces have a combustion outside air intake, which is at least six square inches in area and is e ui ed with a with a readil accessible, operable, and tight fitting damper and or a combustion -air control device. §150(e)2: Continuous burning pilot lights and the use of indoor air for cooling a firebox jacket, when that indoor air is vented to the outside of the building, are prohibited. Space Conditioning, Water Heating and Plumbing System Measures: §110 - §113: HVAC equipment, water heaters, showerheads, faucets and all other regulated appliances are certified by the Energy Commission. §113(c)5: Water heating recirculation loops serving multiple dwelling units and High -Rise residential occupancies meet the air release valve, backflow prevention, pump isolation valve, and recirculation loop connection requirements of §1 13(c)5. §115: Continuously burning pilot lights are prohibited for natural gas: fan -type central furnaces, household cooking appliances (appliances with an electrical supply voltage connection with pilot lights that consume less than 150 Btu /hr are exempt), and pool and spa heaters. 150 h : Heatin and /or cooling loads are calculated in accordance with ASHRAE, SMACNA or ACCA. 41506): Heating systems are equipped with thermostats that meet the setback requirements of Section 112(c). §150(j)1A: Storage gas water heaters rated with an Energy Factor no greater than the federal minimal standard are externally wrapped with insulation having an installed thermal resistance of R -12 or greater. § 150(j)1 B: Unfired storage tanks, such as storage tanks or backup tanks for solar water - heating system, or other indirect hot water tanks have R -12 external insulation or R -16 internal insulation where the internal insulation R -value is indicated on the exterior of the tank. §150(j)2: First 5 feet of hot and cold water pipes closest to water heater tank, non - recirculating systems, and entire length of recirculating sections of hot water pipes are insulated per Standards Table 150 -B. §150(j)2: Cooling system piping (suction, chilled water, or brine lines),and piping insulated between heating source and indirect hot water tank shall be insulated to Table 150 -B and Equation 150 -A. §150(j)2: Pipe insulation for steam hydronic heating systems or hot water systems >15 psi, meets the requirements of Standards Table 123-A. 150 ' 3A: Insulation is rotected from dama e, includin that due to sunlight, moisture, equipment maintenance, and wind. §150(j)3A: Insulation for chilled water piping and refrigerant suction lines includes a vapor retardant or is enclosed entirely in conditioned space. 150(j)4: Solar water-heating systems and /or collectors are certified by the Solar Rating and Certification Corporation. EnergyPro 5.1 by EnergySoft User Number. 1315 RunCode: 2012 -07- 02710:44:00 ID: 0120324 Page 9 of 13 MANDATORY MEASURES SUMMARY: Residential (Page 2 of 3 MF -1 R Project Name Date Potu Residence 71212012 §150(m)1: All air - distribution system ducts and plenums installed, are sealed and insulated to meet the requirements of CIVIC Sections 601, 602, 603, 604, 605 and Standard 6 -5; supply -air and return -air ducts and plenums are insulated to a minimum installed level of R- 4.2 or enclosed entirely in conditioned space. Openings shall be sealed with mastic, tape or other duct - closure system that meets the applicable requirements of UL 181, UL 181 A, or UL 181 B or aerosol sealant that meets the requirements of UL 723. If mastic or tape is used to seal o enin s greater than 1/4 inch, the combination of mastic and either mesh or tape shall be used §150(m)1: Building cavities, support platforms for air handlers, and plenums defined or constructed with materials other than sealed sheet metal, duct board or flexible duct shall not be used for conveying conditioned air. Building cavities and support platforms may contain ducts. Ducts installed in cavities and support platforms shall not be compressed to cause reductions in the cross - sectional area of the ducts. §150(m)2D: Joints and seams of duct systems and their components shall not be sealed with cloth back rubber adhesive duct tapes unless such tape is used in combination with mastic and draw bands. 150(-n)7: Exhaust fans stems have back draft or automatic dampers. §150(m)8: Gravity ventilating systems serving conditioned space have either automatic or readily accessible, manually operated dampers. §150(m)9: Insulation shall be protected from damage, including that due to sunlight, moisture, equipment maintenance, and wind. Cellular foam insulation shall be protected as above or painted with a coating that is water retardant and provides shielding from solar radiation that can cause degradation of the material. 150 m 10: Flexible ducts cannot have porous inner cores. §150(o): All dwelling units shall meet the requirements of ANSI /ASHRAE Standard 62.2 -2007 Ventilation and Acceptable Indoor Air Quality in Low -Rise Residential Buildings. Window operation is not a permissible method of providing the Whole Building Ventilation required in Section 4 of that Standard. Pool and Spa Heating Systems and Equipment Measures: §114(a): Any pool or spa heating system shall be certified to have: a thermal efficiency that complies with the Appliance Efficiency Regulations; an on -off switch mounted outside of the heater; a permanent weatherproof plate or card with operating instructions; and shall not use electric resistance heating or a pilot light. §114(b)1: Any pool or spa heating equipment shall be installed with at least 36" of pipe between filter and heater, or dedicated suction and return lines, or built-up connections for future solar heating. 114(b)2: Outdoor pools ors as that have a heat pump or gas heater shall have a cover. §114(b)3: Pools shall have directional inlets that adequately mix the pool water, and a time switch that will allow all pumps to be set or programmed to run only during off-peak electric demand periods. 150 : Residential pool systems orequipment meet the pump sizing, flow rate, piping, filters, and valve requirements of §1 50 Residential Lighting Measures: §150(k)1: High efficacy luminaires or LED Light Engine with Integral Heat Sink has an efficacy that is no lower than the efficacies contained in Table 150 -C and is not a low efficacy luminaire asspecified by 150(k)2. 150(k)3: The wattage of permanently installed luminaires shall be determined asspecified by 130(d). §150(k)4: Ballasts for fluorescent lamps rated 13 Watts or greater shall be electronic and shall have an output frequency no less than 20 kHz. §150(k)5: Permanently installed night lights and night lights integral to a permanently installed luminaire or exhaust fan shall contain only high efficacy lamps meeting the minimum efficacies contained in Table 150 -C and shall not contain a line- voltage socket or line - voltage lamp holder; OR shall be rated to consume no more than five watts of power as determined by §130(d), and shall not contain a medium screw -base socket. 150(k)6: Lighting integral to exhaust fans, in rooms other than kitchens, shall meet the applicable requirements of §150(k). 150 k 7: All switching devices and controls shall meet the requirements of §1 50(k)7. §150(k)8: A minimum of 50 percent of the total rated wattage of permanently installed lighting in kitchens shall be high efficacy. EXCEPTION: Up to 50 watts for dwelling units less than or equal to 2,500 ft2 or 100 watts for dwelling units larger than 2,500 ft2 may be exempt from the 50% high efficacy requirement when: all low efficacy luminaires in the kitchen are controlled by a manual on occupant sensor, dimmer, energy management system (EMCS), or a multi -scene programmable control system; and all permanently installed luminaries in garages, laundry rooms, closets greater than 70 square feet, and utility rooms are high efficacy and controlled by a manual -on occupant sensor. §150(k)9: Permanently installed lighting that is internal to cabinets shall use no more than 20 watts of power per linear foot of illuminated cabinet. EnergyPro 5.1 by EnergySoff User Number: 1315 RunCode: 2012- 07 -02T10 :44:00 1D: 0120324 Page 10 of 13 MANDATORY MEASURES SUMMARY: Residential (Page 3 of 3) MF -1 R Project Name Date Potu Residence 71212012 §150(k)10: Permanently installed luminaires in bathrooms, attached and detached garages, laundry rooms, closets and utility rooms shall be high efficacy. EXCEPTION 1: Permanently installed low efficacy luminaires shall be allowed provided that they are controlled by a manual -on occupant sensor certified to comply with the applicable requirements of §119. EXCEPTION 2: Permanently installed low efficacy luminaires in closets less than 70 square feet are not required to be controlled by a manual -on occupancy sensor. §150(k)11: Permanently installed luminaires located in rooms or areas other than in kitchens, bathrooms, garages, laundry rooms, closets, and utility rooms shall be high efficacy luimnaires. EXCEPTION 1: Permanently installed low efficacy luminaires shall be allowed provided they are controlled by either a dimmer switch that complies with the applicable requirements of §119, or by a manual - on occupant sensor that complies with the applicable requirements of §119. EXCEPTION 2: Lighting in detached storage building less than 1000 square feet located on a residential site is not re uired to comply with §150(k)11. §150(k)12: Luminaires recessed into insulated ceilings shall be listed for zero clearance insulation contact (IC) by Underwriters Laboratories or other nationally recognized testing /rating laboratory; and have a label that certifies the lumiunaire is airtight with air leakage less then 2.0 CFM at 75 Pascals when tested in accordance with ASTM E283; and be sealed with a gasket or caulk between the luminaire housing and ceiling. §150(k)13: Luminaires providing outdoor lighting, including lighting for private patios in low -rise residential buildings with four or more dwelling units, entrances, balconies, and porches, which are permanently mounted to a residential building or to other buildings on the same lot shall be high efficacy. EXCEPTION 1: Permanently installed outdoor low efficacy luminaires shall be allowed provided that they are controlled by a manual on /off switch, a motion sensor not having an override or bypass switch that disables the motion sensor, and one of the following controls: a photocontrol not having an override or bypass switch that disables the photocontrol; OR an astronomical time clock not having an override or bypass switch that disables the astronomical time clock; OR an energy management control system (EMCS) not having an override or bypass switch that allows the luminaire to be always on EXCEPTION 2: Outdoor luminaires used to comply with Exceptionl to §150(k)13 may be controlled by a temporary override switch which bypasses the motion sensing function provided that the motion sensor is automatically reactivated within six hours. EXCEPTION 3: Permanently installed luminaires in or around swimming pool, water features, or other location subject to Article 680 of the California Electric Code need not be hi h efficac luminaires. §150(k)14: Internally illuminated address signs shall comply with Section 148; OR not contain a screw -base socket, and consume no more than five watts of power as determined according to §130(d). §150(k)15: Lighting for parking lots and carports with a total of for 8 or more vehicles per site shall comply with the applicable requirements in Sections 130, 132, 134, and 147. Lighting for parking garages for 8 or more vehicles shall comply with the applicable requirements of Sections 130, 131, 134, and 146. §150(k)l6: Permanently installed lighting in the enclosed, non - dwelling spaces of low -rise residential buildings with four or more dwelling units shall be high efficacy luminaires. EXCEPTION: Permanently installed low efficacy luminaires shall be allowed provided that they are controlled b an n occupant sensor(s) certified to comply with the applicable requirements of §119. EnergyPro 5.1 by EnergySoft User Number: 1315 RunCode: 2012- 07- 02T10:44 :00 0:0120324 Page 11 of 13 HVAC SYSTEM HEATING AND COOLING LOADS SUMMARY Project Name Date POW Residence 7/2/2012 System Name Floor Area HVAC System 1,877 ENGINEERING CHECKS SYSTEM LOAD Number of Systems 1 COIL COOLING PEAK COIL HTG. PEAK Heating System Out ut er S stem 28,500 Total Room Loads Total out ut Btuh) 28,500 Return Vented Lighting 0 CFM Sensible Latent CFM Sensible 1,024 21,281 793 646 25,018 Out ut (Btuh /s ft 15.2 Return Air Ducts Return Fan Ventilation 0 Supply Fan Supply Air Ducts TOTAL SYSTEM LOAD 717 o 1,064 Cooling System 0 Output per S stem 30,000 0 0 0 0 Total Output (Btuh 30,000 0 717 22,715 793 0 Total Output Tons 2.5 1,064 Total Output Btuhls ft) 16.0 Total Output s ft/Ton 750.8 27,146 Air System CFM per System 0 HVAC EQUIPMENT SELECTION Airflow cfm 0 95% AFUE (13 SEER) 28,502 0 28,500 Airflow (cfmis ft) 0.00 Airflow cfmfTon 0.0 Outside Air (% 0.0% Total Adjusted System Output (Adjusted for Peak Design conditions) TIME OF SYSTEM PEAK 28,502 01 3 Aug PM 28,500 Jan 1 AM Outside Air cfml ft 0.00 Note: values above given at ARI conditions HEATING SYSTEM PSYCHROMETRICS Airstream Temperatures at Time of Heating Peak) 28 OF Outside Air Ar 0 cfm 67 IF 4 AlPe 67 OF 105 IF FNMq -� Heating Coil UTA 4 -� — .104 IF ROOM 68 OF COOLING SYSTEM PSYCHROMETICS Airstream Temperatures at Time of Cooling Peak) 88/68 °F Outside Air' Ar 0 cfm 76 / 62 IF 76/62 °F 55/54 °F LLLEU Cooling Coil 56 / 54 IF 46.3% ROOM ..;, 75 / 61 IF EnergyPro 5.1 by EnergySoft User Number: 1315 Run Code: 2012 -07- 02710:44:00 ID: 0120324 Page 12 of 13 HVAC SYSTEM HEATING AND COOLING LOADS SUMMARY Project Name Potu Residence Date 7/2/2012 System Name HVAC System Floor Area 1,553 ENGINEERING CHECKS SYSTEM LOAD Number of Systems 1 Total Room Loads Return Vented Lighting Return Air Ducts Return Fan Ventilation Supply Fan Supply Air Ducts TOTAL SYSTEM LOAD COIL COOLING PEAK COIL HTG. CFM Sensible Latent CFM 540 11,371 925 369 0 383 0 0 0 0 0 0 383 12,137 2 PEAK Heating S stem Sensible Output per System 17,100 14,418 Total Output Btuh 17,100 613 Output Btuh /s ft 11.0 Cooling System 0 Output per System 18,000 0 Total Output (Btuh ) 18,000 0 Total Output Tons 1.5 613 Total Output Btuh /s ft) 11.6 Total Output s ft/Ton 1,035.3 15,645 Air System CFM per System 0 HVAC EQUIPMENT SELECTION Airflow cfm 0 copy of 95% AFUE (13 SEER) 17,115 0 17,100 Airflow (cfm /s ft) 0.00 Airflow (cfm/Ton ) 0.0 Outside Air %) 0.0% Total Adjusted System Output (Adjusted for Peak Design conditions) TIME OF SYSTEM PEAK 17,115 �o 17,100 Aug 3 PM Jan 1 AM Outside Air cfm /s ft 0.00 Note: values above given at ARI conditions HEATING SYSTEM PSYCHROMETRICS (Airstream Temperatures at Time of Heating Peak) 28 OF Outside Air Ar 0 cfm 67 OF 67 OF 105 OF Heating Coil 104 IF ROOM 68 IF COOLING SYSTEM PSYCHROMETICS Airstream Temperatures at Time of Cooling Peak) 88168 OF Outside Air 0 cfm 751 r,2 IF 75 162 OF 55154 OF Cooling Coil 55154 OF 46.7% ROOM 75 / 62 °F EnergyPro 5.1 by EnergySoft User Number: 1315 RunCode: 2012 -07- 02710:44:00 0:0120324 Page 13 of 13