B-2017-1679 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1679
11018 SYCAMORE DR CUPERTINO,CA 95014-6562(342 56 028) ON-TIME AIR
CONDITIONING&
HEATING INC
PLEASANTON,CA
94588
OWNER'S NAME: TAMBLYN WILLIAM J AND PATTY A TRUSTEE DATE ISSUED:09/27/2017
OWNER'S PHONE:650-996-4207 PHONE NO:(925)872-7326
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C-20 Lic.#817040
Contractor ON-TIME AIR CONDITIONING&HEATING INC Date 09/30/2019 X BLDG _ELECT _PLUMB
X MECH X RESIDENTIAL COMMERCIAL
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. JOB DESCRIPTION:
REPLACE FURNACE(SAME LOCATION);REPLACE AC UNIT
I hereby affirm un.- penalty of perjury one of the following two declarations: (SAME LOCATION);REPLACE COIL SAME LOCATION
1. I have:nd will maintain a certificate of consent to self-insure for Worker's
Co'pensation,as provided for by Section 3700 of the Labor Code,for the
. rformance 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. Sq.Ft Floor Area: Valuation:$21754.00
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 APN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 342 56 028
representatives of this city to enter upon theabove mentioned property for
inspection purposes. (We)agree to save indemnify and keep harmless the •
City of Cupertino against liabilities,judgments costs,and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in conseque. e of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE ORAdditionally,the applicant understands d will comply with all non-point
source regulations per the Cuperti • unicipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signatur-� � � Date 09-27-2017 Issued by:Kim Dunbar
Date:09/27/2017
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS:
following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
1. 1,as owner of the property,or my employees with wages as their sole installed without first obtaining an inspection,[.agree to remove all new materials for
compensation,will do the work,and the structure is not intended or offered for inspection:
sale(Sec.7044,Business&Professions Code)
2. l,,as owner of the property,am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(Sec.7044,Business&Professions Code). Date:09-27-2017
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER.
s. '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 I
performance of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
2. ,I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534. I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
3. I certify that in the performance of the work for which this permit is issued,I Health&Safety.Code,Section 25532(a)should I store or handle hazardous
material. Additionally,should I use equipmentor devices which emit haz: dous
shall not employ any person in,any manner so as to become subject to the air contaminants as defined by the Bay Area lAir Quality Managemen i istrict I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertino;Municipal Code,Ch :ter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety C e,Sections;25505,25533,a 5534.
Labor Code,I must forthwith comply with such provisions or this permit shall I
be deemed revoked. Owner or authorized age :���„
APPLICANT CERTIFICATION Date:09-27-2017
I certify that I have read this application and state that the above information is CONSTRUCTION LENDING AGENCY
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending agency for the performance
relating to building construction,and hereby authorize representatives of this city of work's for which this permit is issued(Sec :!3097 ,Civ C.)
to enter upon the above:mentioned property for inspection purposes. (We)agree Lender's Name i .
to save indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs,and expenses which may accrue against said City in Lender's Address
consequence of the granting of this permit. Additionally;the applicant understands
and will comply with all non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION
Code,Section 9.18. I understand my plans shall be used as public records.
Signature Date 09-27-2017 Licensed
ti
CONSTRUCTION PERMIT APPLICATION
�`/0,1/4/ COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
{{ 10300 TORRE AVENUE • CUPERTINO,CA 95014-3255
y-t;rss �r1
w44 l-0(408) 777-3228 • building@cupertino.org PEMIT#B- 11-- - ALA
CUPERTINO REV# DEF#
D❑ NEW�jCONSTRUCTION
r❑ADDITION ❑ALTERATION ❑T.I. ❑MEP ❑RE-ROOF ❑SWIMMING POOL/SPA
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STREETADDRESS w`6/I
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NAME 0 OWNER-BUILDER COMPANY LICENSE NU ER LICENSE TYPE
ISESS Q /ATE, ZIP I,7I
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0 ARCHITECT ❑OWNER ❑OWNER AGENT ONTRACTOR AGENT 0
ENGIINEER 0 DEVELOPER 0 TENANT '
CONAAME fGQ E V(...)a 1le/ Gdz-i- / eKf !� a Ww�
STREET D�7S� 4 jr, ! ^ lv it.y. 3 CINE ZIP �74-N PHONEi� 7--�
DECRIPTON Cw�-�( �7...e. ^ e 80 9 iq / ( - ) �^ c /
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fISINGLE-FAMILY/DUPLEX 0 MULTI-FAMILY 0 INDUSTRIAL 0 COMMERCIAL I
STING USE EXISTING SF NEW FLOOR SF PORCH SF DECK SF DEMO SF STORIES# TOTAL NET SF USE TYPE OCC SQ:FT. VALUATION($)
REMODEL REMODEL KITCHEN REMODEL OTHR (GARAGE ❑ATTACHED
BATHROOM SFS ' SF SF SF 0 DETACHED
FIREI
ISPRINKLERS❑�NO EICHLER 0 YESD SECOND STORY ADDITION ONO
IDWELLING SECOND DWELLING ❑yES ❑ATTACHED❑DETACHED OTHER
tm rrs# UNIT'ADDITON: I ❑NO , S F
POOLS( 0 FIBERGLASS' ❑VINYL-LINED 0 GUNITE 0 PREFABRICATED I
POOL-SF . ' SPA-SFS •i I1,.SPA'ATTACHED❑YES 0 NO I TOTAL-SF
tRECE BY: �ALU�TI
` N:
Commercial or Multi-Fanu .Buildmgg with Public Swimming Pools requires Department of Environmental Heath approval
RE-ROOF(EXISTING ROOF TYPE: ❑BUIL'T--UP ROOF❑ASPHALT SHINGLES❑WOOD SHAKES❑WOOD SHINGLES❑TILE OTHER(SPECIFY)
REMOVE/REPLACE Q NO IFNO PLYWOOD I=1 1/2" ❑3/8" PLYWOOD TYPE: PITCH: ROOF CLASS
IEI YESI #9F LAYERS THICKNESS❑5/8" OTHER ❑OSB ❑CDX OTHER •12 A
PROPOSED ROOF TYPE:❑BUILT-UP ROOF DASPHALT SHINGLES 0 WOOD SHAKES DWOOD SHINGLES 0 OTHER
*Provide a signed copy of the'Cupertiino's Tear-Off Policy SF Sof SQUARES
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 building cons on. I authorize representatives of Cupertino to
enter the above-identified property.for inspection purposes. I ac a ledge and a, orize all information contained on •'s application form
to be made available for public record.
Signature of Applicant/Agent: JI. Date: '
V'
.
SUPPLEMENTAL INFORMATION REQUIRED
*New SFD/Second Dwelling Units/Multifamily Dwellings:A Demolition permit is required prior to issuance of a building permit for all new construction.
*Commercial Buildings: Provide a completed Hazardous Materials Disclosure form if any Hazardous Materials are being used Ls part of this project.
*Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application.
*HOA-Provide a'letter of approval from the Home Owner's Association ,
1
}, BldgApp 2017.doc revised 08/01/17
CERTIFICATE OF COMPLIANCE
CF1R-ALT 02-E
Alterations to Space Conditioning Systems(formerly CF-1R-ALT-HVAC) (Page 1 of 3)
Project Name: BILL TAMBLYN Date Prepared: 2017-09-27
A.General Information
CF1R-ALT-02 is applicable to multiple space conditioning systems contained within a single dwelling unit.When multiple dwelling units must be documented,use one
CF1R-ALT-02 document for each dwelling unit.
01 Project Name BILL TAMBLYN 02 Date Prepared 2017-09-27
03 Project Location 11018 SYCAMORE DRIVE 04 Building Type Single family
05 CA City Cupertino ` 06 Dwelling Unit Name HOUSE
i `7
I ` ' ' ;' Dwelling Unit Conditioned
07 Zip Code 95014 1' - N. 08 I i 2815
iFloor Area(ft2)
r:ts L. 1t Number of Space
09 Climate Zone 4 — 110` Conditioning(SC)Systems in 1
: r` this Dwelling Unit:
B.Space Conditioning(SC)System Information '. i
01 02 03 04 v'---- LI Tj o5,�- iU6' i 07 08 09 10 .
Is the SC Installing a, -- {iml.i int,r r'4 h
CFA served �.'ii F.a `• r +_ y
SC System SC System systema refrigerant installing new SC Installing Installing Installing
Identification or Location or Area by this SC ducted containing system more than 40 entirely new entirely new
Name Served System(ft2) system? component? components? feet of ducts? duct system? SC system? Alteration Type
SYSTEM 1 LOCATION 1 2815 - Yes Yes Yes No No No
Altered space
conditioning system
C. Extension of Existing Duct System,Greater Than_40 Feet(Section150.2(b)1Diib) -
This section does not apply to this project.
Registration Number:417-A020118761A-000-000-0000000-0000 Registration Date/Time:2017-09-27 09:25:03 HERS Provider:CHEERS
CA Building Energy Efficiency Standards-2016 Residential Compliance Report Version:2016.1.006 Report Generated:2017-09-27 09:25:04
Schema Version:rev 10/16
CERTIFICATE OF COMPLIANCE CF1R-ALT 02-E
Alterations to Space Conditioning Systems(formerly CF-1R-ALT-HVAC) (Page 2 of 3)
D.Altered Space Conditioning System (Sections 150.2(b)1E and F)
01 02 03 04 05 06 07 08 09 10 11 12
Heating Cooling
System Heating Altered Heating Minimum Altered Cooling Minimum Required New or
Identification System Heating Efficiency Efficiency Cooling Cooling Efficiency Efficiency Thermostat Replaced New Duct
or Name Type Components Type Value System-Type Components Type - Value Type Duct Length R-Value- - - --
All new All new This field or This field or
SYSTEM 1 Central gas heating AFUE 0.8 Central split cooling SEER 14 Setback section is not section is not
furnace components AC components applicable applicable
Required Documentation: .- ,
CF2R-MCH-01-E-Space Conditioning Systems i #k(/ ,
-Duct insulation requirement for the new portions of supply-air and return-air ducts or plenums rR6'(CZ 1 10;12 na d 13)and R8(CZ 11 and 14-16)
CF2R and CF3R-MCH-20-H-Duct Leakage Test required when heating or cooling components are installed in,ducYedsystems,or when more than 40 ft of duct length is replaced
-Leakage rate compliance:<=15%or<=10%leakage to outside,or seal all accessible leaks ._ -L-3 L —..,?
CF2R and CF3R-MCH-25-H Refrigerant Charge verification required when refrigerant containing co p nents are mstalled or altered(applicable in CZ 2,8-15).
CF2R and CF3R-MCH-23 Airflow Rate>=300 CFM per ton required when MCH-25 is required. k1� if/
Exceptions:
-Duct systems registered with HERS provider as previously sealed are exempt from MCH-20 Duct Leakage Test g requirements.
-Heating-only systems and Air Handler Furnace changes do not require verification of Air Flow MCH-23,or-Refrigerant Charge MCH-25.
-Existing duct systems constructed,insulated or sealed with asbestos are exempt from MCH-20 Duct Leakage Testing requirements.
,.. : 'tIA 'i«=a i-= ll Y,v
E. Entirely New or Complete Replacement Duct System,with or without`Equipment Changeout(Sections 150.2(b)1Diia and 150.2(b)1E, F)
►,,:[:, tehtacl ozrii�wWitt,.w Ir LT1rit;,.
This section does not-apply to this-project.
F. Entirely New or Complete Replacement Space Conditioning System (Section 150.2(b)1C) -
This section does not apply to this project.
Registration Number:417-A020118761A-000-000-0000000-0000 Registration Date/Time:2017-09-27 09:25:03 HERS Provider:CHEERS
CA Building Energy Efficiency Standards-2016 Residential Compliance Report Version:2016.1.006 Report Generated:2017-09-27 09:25:04
Schema Version:rev 10/16
CERTIFICATE OF COMPLIANCE CF1R-ALT-02-E
Alterations to Space Conditioning Systems(formerly CF-1R-ALT-HVAC) (Page 3 of 3)
Documentation Author's Declaration Statement
1. I certify that this Certificate of Compliance documentation is accurate and complete. -
Documentation Author Name: - - - -7 - Documentation Author Signature:
April Rodriguez _ - - - -tlprLLRotiv%gueij_
Company: - Signature Date:"
I Permit E Raters 2017-09-27
Address: CEA/HERS Certification Identification(if applicable):
31225 La Baya Drive
City/State/Zip: Phone:
Westlake Village CA 91362 d Vis' 818735-7876
Responsible Person's Declaration statement '41
I certify the following under penalty of perjury,under the laws of the State of California: 'I
1. The information provided on this Certificate of Compliance is true and correct.
2. I am eligible under Division 3 of the Business and Professions Code to accept responsibility-for the building design or system design identified on this Certificate of Compliance(responsible designer).
3. That the energy features and performance specifications,materials,components,and manufactured devices for the building design or system design identified on this Certificate of Compliance conform to the
requirements of Title 24,Part 1 and Part 6 of the California Code of Regulations.
4. The building design features or system design features identified on this Certificate of Compliance are consistent with the information provided on other applicable compliance documents,worksheets,
calculations,plans and specifications submitted to the enforcement forirpproval with this sbwlding permit application.
5. I will ensure that a registered copy of this Certificate of Compliance shall be.madejjavailable`with thle buildinig permit(s)•issued for the building,and made available to the enforcement agency for all applicable
inspections.I understand that a registered copy of this Certificate of Compliance is'required'to be'i cTded With`the dbc`umentation the builder provides to the building owner at occupancy.
Responsible Designer Name: iResponsible Designer Signature:Zili'tChe x Sar � LYUcFlLyndy Rose
Company: Date Signed:
On-Time Air Conditioning&Heating Inc dba Service Champions 2017-09-27
Address: License:
7020 Commerce Drive 817040
City/State/Zip: - - Phone: -
Pleasanton CA 94588 925-444-4444
Digitally signed by CHEERSTM. This digital signature is provided in order to secure the content of this registered
document, and in no way implies Registration Provider responsibility for the accuracy of the information.
Registration Number:417-A020118761A-000-000-0000000-0000 Registration Date/Time:2017-09-27 09:25:03 HERS Provider:CHEERS
CA Building Energy Efficiency Standards-2016 Residential Compliance Report Version:2016.1.006 Report Generated:2017-09-27 09:25:04
Schema Version:rev 10/16
'risi SMOKE / CARBON MONOXIDE ALARMS
OWNER CERTIFICATE OF COMPLIANCE
is COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
1 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
GUPERTI[
(408)777-3228•FAX(408)777-3333•buildincAcupertino.orq
PERMIT CANNOT BE FOULED UNTIL THISCERTIFICATE HAS BEEN
COMPLETED,SIGNND,AND,RETURNED TO THE BUILDING DIVISION
PURPOSE
This affidavit is a self-certification for the installation of all required Smoke and Carbon Monoxide Alarms for
compliance with 2016 CRC Section R314,R315,2016 CBC Sections 420 6 and 907.2.11.2 where no interior access
for inspections are required.
GENERAL INFORMATION
Existing single-family and multi-family dwellings shall be provided with Smoke Alarms and Carbon
Monoxide alarms. When the valuation of additions, alterations,or repairs to existing dwelling units exceeds
$1000.00, CRC Section R314,R315, and CBC Sections 907.2.11.5 and 420 6 require that Smoke Alarms and/or
Carbon Monoxide Alarms be installed in the following locations.
AREA SMOKE ALARM CO ALARM
Outside of each separate sleeping area in the immediate vicinity of the X X
bedroom(s)-(Smoke alarms shall not be located within 3 feet of bathroom door)
On every level of a dwelling unit including basements and habitable attics X X
Within each sleeping room X
Carbon Monoxide alarms are not required in dwellings which do not contain fuel-burning appliances and that
do not have an attached garage. Carbon monoxide alarms combined with smoke alarms shall comply with
CBC Section 420 6 and shall be approved by the Office of the State Fire Marshal.
Power Supply In dwelling units with no commercial power supply, alarm(s)may be solely battery operated.
In existing dwelling units, alarms are permitted to be solely battery operated where repairs or alterations do
not result in the removal of wall and ceiling finishes or there is no access by means of attic,basement or crawl
space.Refer to CRC Section R314 and CBC Sections 907.2.11.4 and 420.6.2.An electrical permit is required for
alarms which must be connected to the building wiring.
As owner of the above-referenced property,I hereby certify that the alarm(s) referenced above has/have been
installed in accordance with the manufacturer's instructions and in compliance with the California Building
and California Residential Codes.The alarms specified below have been tested andare operational, as of the
date signed below
Address: //O/a S'' CAya eeicit,
' Permit No. 13 "Zv s 7 _!L 7f
Specify Number of Alarms #Smoke Alarms.IIMI #Carbon Monoxide Detectors. I Z- ,
I have read and agree to comply with the terms and conditions of this statement
Owner(or Owner Agent's)Name:
M...4-44". 1-41--'3`Yj �. l Cy CZ�/!
Signature �/✓...... .. ` Date: . ...
Contractor Name: � ���� � ••�
Signature Lic.#
Date:
Smoke and COform.doc revised 01/10/2017
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CERTIFICATE OF INSTALLATION " " CF2R-MCH-20-H
Duct Leakage Diagnostic Test (Page 1 of 3)
Project Name: BILLTAMBLYN Enforcement Agency: Cupertino Permit Number: B2017-1679
(City of)
Dwelling Address: 11018 SYCAMORE DRIVE City: Cupertino Zip Code: 95014
A.System Information
01 Space Conditioning System Identification or Name SYSTEM 1
02 Space Conditioning System Location or Area Served LOCATION 1
03 Building Type from CF-1R Single family
04 Verified Low Leakage Ducts in Conditioned Space(VLLDCS) No,credit is not taken
Credit from CF1R?
Verified Low Leakage Air Handling Unit(VLLAHU)Credit No,credit'is not taken
05 from CF1R?
06 Duct System Compliance Category Alteration using smoke test
MCH-20e-Sealing All Accessible Leaks using Smoke Test
B. Duct Leakage Diagnostic Test
01 Condenser Nominal Cooling Capacity(ton) . 5
02 Heating Capacity(kBtu/h) 70
03 Conditioned Floor Area served by this HVAC system(ft2) 2815
04 Duct Leakage Test Conditions Test final
05 Duct Leakage Test Method Total leakage
06 Leakage Factor 0.15
07 Air Handling Unit Airflow(AHUAirflow)Determination Cooling system method
Method
08 Measured AHUAirflow This field or section is not applicable
09 Calculated Target Allowable Duct Leakage(cfm) 300
10 Actual Duct Leakage Rate from Leakage Test Measurement 382
(cfm)
Registration Number: <- ° Registration Date/Time:2017-1047 12:16:42 HERS Provider:CHEERS
417-A020118761A-005-000-M20000A-0000
CA Building Energy Efficiency Standards Report Version:2016.1.006 Report Generated:2017-10-17 12:16:44
2016 Residential Compliance Schema Version:rev 03/16
CERTIFICATE OF INSTALLATION CF2R-MCH-20-H
Duct Leakage Diagnostic Test (Page 3 of 3)
Documentation Author's Declaration Statement
1. I certify that this Certificate of Installation documentation is accurate and complete.
Documentation Author Name: Documentation Author Signature:
April Rodriguez Apri.Lt2.odrUy e
Company: Signature Date:
I Permit E Raters 2017-10-17
Address: CEA/HERS Certification Identification(if applicable):
31225 La Baya Drive
City/State/Zip: Phone:
Westlake Village CA 91362 818-735-7876
Responsible Person's Declaration statement
I certify the following under penalty of perjury,under the laws of the State of California:
1. The information provided on this Certificate of Installation is true and correct.
2. I am either:a)a responsible person eligible under Division 3 of the Business and Professions Code in the applicable classification to accept
responsibility for the system design,construction,or installation of features,materials,components,or manufactured devices for the scope of work
identified on this Certificate of Installation and attest to the declarations in this statement,or b)I am an authorized representative of the responsible
person and attest to the declarations in this statement on the responsible person's behalf.
3. The constructed or installed features,materials,components or manufactured devices(the installation)identified on this Certificate of Installation
conforms to all applicable codes and regulations and the installation conforms to the requirements given on the Certificate of Compliance,plans,and
specifications approved by the enforcement agency.
4. I understand that a HERS rater will check the installation to ver'ify compliance and if such checking determines the installation fails to comply,I am
required to offer any necessary corrective action at no charge to the building owner.
5. I will ensure that a registered copy of this Certificate of Installation shall be posted,or made available with the building permit(s)issued for the
building,and made available to the enforcement agency for all applicable inspections.I understand that a registered copy of this Certificate of
Installation is required to be included with the documentation the builder provides to the building owner at occupancy.
•
•
Responsible Builder/Installer Name: Responsible Builder/Installer Signature:
Lyndy Rose Lyndy Rase/
Company Name:(Installing Subcontractor or General Contractor or Position With Company(Title):
Builder/Owner) Contractor/Installer
On-Time Air Conditioning&Heating Inc dba Service Champions
Address: CSLB License: e
7020 Commerce Drive 817040
City/State/Zip: Phone: Date Signed:
Pleasanton CA 94588 925-444-4444 2017-10-17
Third Party Quality Control Program(TPQCP)Status: Name of TPQCP(if applicable):
Digitally signed by CHEERS"'. This digital signature is provided in order to secure the content of this registered
document, and in no way implies Registration Provider responsibility for the accuracy of the information.
Registration Number: Registration Date/Time:2017-10-17 12:16:42 HERS Provider:CHEERS
417-A020118761A-005-000-M20000A-0000
CA Building Energy Efficiency Standards Report Version:2016.1.006 Report Generated:2017-10-17 12:16:44
2016 Residential Compliance Schema Version:rev 03/16
CERTIFICATE OF VERIFICATION GF3R MCH 20 H
Duct Leakage Diagnostic Test (Page 1 of 3)
Project Name: BILL TAMBLYN Enforcement Agency: Cupertino Permit Number: B2017-1679
(City of)
Dwelling Address: 11018 SYCAMORE DRIVE City: Cupertino Zip Code: 95014
A.System Information
01 Space Conditioning System Identification or Name SYSTEM 1
02 Space Conditioning System Location or Area Served LOCATION 1
03 Building Type from CF-1R Single family
04 Verified Low Leakage Ducts in Conditioned Space(VLLDCS) No,credit is not taken
Credit from CF1R?
05 Verified Low Leakage Air Handling Unit(VLLAHU)Credit No,credit is not taken
from CF1R?
06 Duct System Compliance Category Alteration using smoke test
MCH-20e-Sealing All Accessible Leaks using Smoke Test
B. Duct Leakage Diagnostic Test
01 Condenser Nominal Cooling Capacity(ton)
5
02 Heating Capacity(kBtu/h) 70
03 Conditioned Floor Area served by this HVAC system(ft2) 2815
04 Duct Leakage Test Conditions Test final
05 Duct Leakage Test Method Total leakage
06 Leakage Factor 0.15
07 Air Handling Unit Airflow(AHUAirflow)Determination Cooling system method
Method
08 Measured AHUAirflow This field or section is not applicable
09 Calculated Target Allowable Duct Leakage Rate(cfm) 300
10 Actual Duct Leakage Rate from Leakage Test 382
Measurement(cfm)
Registration Number: Registration Date/Time:2017-10-17 12:17:02 HERS Provider:CHEERS
417-A020118761 A-005-000-M 2 0000A-M 2 oA
CA Building Energy Efficiency Standards. Report Version:2016.1.006 Report Generated:2017-10-17 12:17:03
2016 Residential Compliance Schema Version:rev 03/16
CERTIFICATE OF VERIFICATION CF3R MCH-20 H
Duct Leakage Diagnostic Test
(Page 3 of 3)
Documentation Author's Declaration Statement
1. I certify that this Certificate of Verification documentation is accurate and complete.
Documentation Author Name: Documentation Author Signature:
April Rodriguez April1?odrique
Company: Date Signed:
I Permit E Raters 2017-10-17
Address: CEA/HERS Certification Identification(if applicable):
31225 La Baya Drive
City/State/Zip: Phone:
Westlake Village CA 91362 818-735-7876
Responsible Person's Declaration statement
I certify the following under penalty of perjury,under the laws of the State of California:
1. The information provided on this Certificate of Verification is true and correct.
2. I am the certified HERS Rater who performed the verification identified and reported on this Certificate of Verification(responsible rater).
3. The installed features,materials,components,manufactured devices,or system performance diagnostic results that require HERS verification
identified on this Certificate of Verification comply with the applicable requirements in Reference Appendices RA2,RA3,and the requirements
specified on the Certificate of Compliance for the building approved by the enforcement agency.
4. The information reported on applicable sections of the Certificate(s)of Installation(CF2R)signed and submitted by the person(s)responsible for the
construction or installation conforms to the requirements specified on the Certificate(s)of Compliance(CF1R)approved by the enforcement agency.
5. I will ensure that a registered copy of this Certificate of Verificatiorishall be posted,or made available with the building permit(s)issued for the
building,and made available to the enforcement agency for all applicable"inspections.I understand that a registered copy of this Certificate of
Verification is required to be included with the documentation the builder provides to the building owner at occupancy.
Builder Or Installer Information As Shown On The Certificate Of Installation
Company Name(Installing Subcontractor,General Contractor,or Builder/Owner):
On-TimeAirConditioning&Heating Inc dba Service champions _
Responsible Builder or Installer Name: CSLB License:
Lyndy Rose 817040
HERS Provider Data Registry Information
Sample Group Number(if applicable): Dwelling Test Status in Sample Group(if applicable)
N/A
HERS Rater Information
HERS Rater Company Name:
I Permit E Raters
Responsible Rater Name: Responsible Rater Signature:
Josh Lertzman Josh,Lert-kmaw
Responsible Rater Certification Number w/this HERS Provider: Date Signed:
RCN13251 2017-10-17
Digitally signed by CHEERS'". This digital signature is provided in order to secure the content of this registered
document, and in no way implies Registration Provider responsibility for the accuracy of the information.
Registration Number: Registration Date/Time:2017-10-17 12:17:02 HERS Provider:CHEERS
417-A020118761A-005-000-M 20000A-M 20A
CA Building Energy Efficiency Standards Report Version:2016.1.006 Report Generated:2017-10-17 12:17:03
2016 Residential Compliance Schema Version:rev 03/16
CERTIFICATE OF VERIFICATION CF3R-MCH-20-H
Duct Leakage Diagnostic Test (Page 2 of 3)
B. Duct Leakage Diagnostic Test
System passes using smoke test of an altered HVAC system in an existing building. No
visible smoke exits the accessible portions of the duct system.Smoke is only emanating
from air-handling unit(AHU)cabinet and non accessible portions'of the duct system.Note
11 Compliance Statement: -Accessible is defined as having access thereto,but which first may require removal or
opening of access panels,doors,or moving similar obstructions.If access to the ducts
requires an object to be demolished or deconstructed then sealing of those ducts is not
required
12 Notes:
C.Additional Requirements for Compliance
01 System was tested in its normal operation condition.No temporary taping allowed.
Outside air(OA)duct connections to the central forced air duct system shall not be sealed/taped off during duct leakage
02 testing.OA ducts used for Central Fan Integrated(CFI) Indoor Air Quality ventilation systems,or Central Fan Ventilation
Cooling Systems,that utilize dampers that open only when OA is required and automatically close when OA is not required,
may configure the OA damper to the closed position during duct leakage testing.
03 All supply and return register boots were sealed to the drywall.
04 Building cavities were not used as plenums or platform returns in lieu of ducts.
05 If cloth backed tape was used it was covered with Mastic and draw bands.
06 All connection points between the air handler and the supply and return plenumsare completely sealed.
If the system complies using the Smoke Test method,the smoke test was conducted in accordance with the requirements
07 of Reference Residential Appendix RA3.1.4.3.6.Systems that comply using smoke test shall not be included in sample
groups for HERS verification compliance.
08 Verification Status:: Pass-all applicable requirements are ref
09 Correction Notes:
The responsible person's signature on this compliance document affirms that all applicable requirements in this table have
been,met unlessotherwise noted in the Verification Status and the Corrections Notes in this table.
D. Determination of HERS Verification Compliance
All applicable sections of this document shall indicate compliance with the specified verification protocol requirements in order
for this Certificate of Verification as a whole to be determined to be in compliance.
01 Complies:All specified verification protocol requirements on this document are met.
Registration Number: Registration Date/Time:2017-10-17 12:17:02 HERS Provider:CHEERS
417-A020118761A-005-000-M 20000A-M20A
CA Building Energy Efficiency Standards Report Version:2016.1.006 Report Generated:2017-10-17 12:17:03
2016 Residential Compliance Schema Version:rev 03/16