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15080195R&V"I CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: 15080195 20153 JOHN DR CUPERTINO CA 95014 (369 33 038) DE ANZA BUILDERS SAN JOSE, CA 95129 OWNER'S NAME: MCLEOD DAVID AAND MOKRZYCKI MARIA DATE ISSUED: 11/12/2015 OWNER'S PHONE: 650-279-6540 PHONE NO: (408) 865-0222 LICENSED CONTRACTOR'S DECLARATION BUII,DING PERMIT INFO: License Class U Lic. #943227 Contractor DE ANZA BUILDERS Date 02/28/2018 —BLDG _ELECT _ PLUMB I hereby affirm that am licensed under the provisions of Chapter 9 (commencing MECH _ RESIDENTIAL COMMERCIAL with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. JOB DESCRIPTION: ADD 581 S.F. TO FRONT TO CREATE 2 (I) BEDROOMS & 1 I hereby affirm under penalty of perjury one of the following two declarations: (N) BATHROOM. REPLACE 2 (E) WINDOWS t. 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 REV#1 - SHORTEN EAVE OVERHANG; ADD STONE VENEER TO performance of the work for which this permit is issued. f EXTERIOR; ADD PSL & 5" INCH CHANNEL TO SUPPORT I have and will maintain Worker's Compensation Insurance, as provided for by EXTERIOR 2ND FLOOR WALL. Section 3700 of the Labor Code, for the performance of the work for which this ISSUED, 6/8/2016 permit is issued. APPLICANT CERTIFICATION **BINA4** I certify that I have read this application and state that the above Sq. Ft Floor Area: Valuation: $120000.00 information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize APN Number: Occupancy Type: representatives of this city(A enter upon the above mentioned property for inspection purposes. (W ) a ree to save indemnify and keep harmless the 369 33 038 City of Cupertino against liabil les, judgments, costs, and expenses which may accrue against said ityi consequence of the granting of this permit. Additionally, the applicanund rstands and will comply with all non -point source regulations per th Cu ertino Municipal Code, Section 9.18. PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR Signature-, z Date 6/s/2016 180 DAYS FROM LAST CALLED INSP CTION. OWNER -BUILDER DEC LAVTION Issued by: ALEX VALLELUNGA I hereby affirm that I am exempt from the Contractor's License Law for one of the Date: 11/12/2015 following two reasons: r. I, as owner of the property, or my employees with wages as their sole RE -ROOFS: compensation, will do the work, and the structure is not intended or offered for All roofs shall be inspected prior to any roofing material being installed. If a roof is sale (Sec.7044, Business & Professions Code) installed without first obtaining an inspection, I agree to remove all new materials for 2. I, as owner of the property, am exclusively contracting with licensed inspection. contractors to construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three declarations: Signature of Applicant: 1. I have and will maintain a Certificate of Consent to self -insure for Worker's Date: 6/8/2016 Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER 2. 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 HAZARDOUS MATERIALS DISCLOSURE permit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the s. I certify that in the performance of the work for which this permit is issued, I California Health & Safety Code, Sections 25505, 25533, and 25534. I will shall not employ any person in any manner so as to become subject to the maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Worker's Compensation laws of California. If, after making this certificate of Health & Safety Code, Section 25532(a uld I store or handle hazardous exemption, I become subject to the Worker's Compensation provisions of the material. Additionally, should I use equipmen or devices which emit hazardous Labor Code, I must forthwith comply with such provisions or this permit shall contaminants as defined by the Bay ?area Quality Management District I will maintain compliance with the Cupe"o M nicipal Code, Chapter 9.12 and be deemed revoked. the Health & Safety Code, Sections 25 05, 25533, and 25534. APPLICANT CERTIFICATION I certify that 1 have read this application and state that the above information is Owner or authorized agent: v il correct. I agree to comply with all city and county ordinances and state laws ,Date: -6/8/2016 - - - relating to building construction, and hereby authorize representatives of this city CONSTRUCTION LETDING A EN Y to enter upon the above mentioned property for inspection purposes. (We) agree I hereby affirm that there is a construction nding agency for the performance to save indemnify and keep harmless the City of Cupertino against liabilities, of work's for which this permit is issued (Sec. 3097, Civ C.) judgments, costs, and expenses which may accrue against said City in Lender's Name consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Lender's Address Code, Section 9.18. Signature Date 6/8/2016 ARCHITECT'S DECLARATION 1 understand my plans shall be used as public records. Licensed Professional COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014=3255 CIJPER' INO (408) 777-3228 • FAX (408) 777-3333 e buildingg-cupertino.orq NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION / TI X REVISION / DEFERRED Vl ORIGINAL PERMIT # PROJECT ADDRESS 7 _7N 9 OwNERI �CS.en4� -�" P o 'S`i5- k" 'tc. i�oil�t'z !JG avu. Mho -% w►�lsr,r STREET ADDRESS Ze% 1� .CRATE,2V FAX '7 J �' '��"�.�w. ✓" CONTACT NAME PHONE ` cyb 3 .1 E-NIAIL �M-•c \<.«�-,�1.wc ers. STREET ADDRESS l I Z0 L:e {,�e o��.. W CITY, STATE; ZIP FAX ep. eco s 11 OWNER ❑ OWNER-BUn:DER ❑ OWNER AGENT `g'CONTRACTOR 11 CONTRACTORAGENT ❑ ARCHITECT 11 ENGINEER Q. DEVELOPER 11 TENANT CONTRACTORwNAA. ME LICE SE �ER - ISCENSE E .BUS. LIC 41 a r' �.-�rC..�'GNuhe.�,.y�, d tIo �6 ` COMPANY NnMR V"C.pe.v+z.C_ %v'L\A e,4. E-MAIL talk FAX STREET ADDRESS CITY, STATE, ZIP P ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC If COMPANY NAAM E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK S 1r, o� e.,ti. e�.� � o+�w✓�a-v�. c3�. d. � oar• -c. Jc��r. �-- � c t o a SSL .� 4; b'&.%*� A EXISTINGUSE . - PROPOSED USE -- CONSTR TYPE - # STORIES USE TYPE OCC SQFT- VALUATION (S) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NETAREA BATHROOM KITCHEN - OTHER - - - -. REMODEL AREA REMODEL AREA REMODEL AREA PORCHAREA, - DECKAREA TOTAL DECKlPORCHAREA GARAGE AREA .DETACH O ATTACH ,#DWELLINGUNPPS: IS A SECOND UNIT OYES SECONDSTORY OYES BEINGADDED? ONO ADDITION? ONO e PRE -APPLICATION 1-1 YES W YES,. PROVIDE COPY OF IS THE BLDG AN ❑YES RECEIVED $ -- `: _TOTAL VALUATION_ PLANNINGAPPL# ONO PLANNINGAPPROrl. LEITER EICHLERHOME? FlNO By my signature below, I certify to each ofe Mowing: I am the property owner or authorized agent to act on the property Owne ehalf. I have read this application and the information I have provi ed 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 b ildin co truction. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes. Signature of ApplicanVAgent: Dater l v tP SUPPLEMENTAL INFO TION REQUIRED PLANGIIECKTYPE . xoaTING SLIP OVER, -THF -COUNTER ❑ BURMING PIAN 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. Q wwoms 171- PLANNINGPLANREVICw _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure I l STA"ARD PITBLIC woxxs form if any Hazardous Materials are being used as part of this project. LARGI; 0'F RriEPr _ Copy of Planning Approval Letter or Meeting with Planning prior to 0 MAJOR [( 'SANITARySEWER DISTRICT submittal of Building Permit application. IT ENVIRONMENTAL HEALTH BldgApp 2011.doc revised 06121111 ;9s -A CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: 15080195 20153 JOHN DR CUPERTINO CA 95014 (369 33 038) DE ANZA BUILDERS SAN JOSE, CA 95129 OWNER'S NAME: MCLEOD DAVID AAND MOKRZYCKI MARIA DATE ISSUED: 11/12/2015 OWNER'S PHONE: PHONE NO: (408) 865-0222 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class B tic. #943227 Contractor DE ANZA BUILDERS Date 02/28/2018 —BLDG —ELECT _PLUMB MECH 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: ADD 581 S.F. TO FRONT TO CREATE 2 (N) BEDROOMS & 1 I hereby affirm under penalty of perjury one of the following two declarations: (N) BATHROOM. REPLACE 2 (E) WINDOWS r. 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 jWN, Section 3700 of the Labor Code, for the performance of the work for which this I, permit is issued. APPLICANT CERTIFICATION Sq. Ft Floor Area: Valuation: $120000.00 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 369 33 038 representatives of this city to enter upon the above mentioned property for inspectionpurp (We) agree to save indemnify and keep harmless the City of Cuperti o ag 'nst liabilities, judgments, costs, and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED may accrue ag inst s id City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR Additionally, the appli nt understands and will comply with all non -point source regulatio s pe the Cupertino Municipal Code, Section 9.18. 180 DAYS FROM LAST CALL D INSP TION. i14 ;Signature_ Date �/ 12016 Issued by: ALEX VALLELUNGA Date: 11/12/2015 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 L 1, as owner of the property, or my employees with wages as their sole installed without first obtaining an inspection, I 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. I, as owner of the property, am exclusively contracting with licensed Signature of Applicant: contractors to construct the project (Scc.7044, Business & Professions Code). Date: 4/5/2016 1 hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER r. 1 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. 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 n Section 3700 of the Labor Code, for the performance of the work for which this California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will permit is issued. maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the 3. 1 certify that in the performance of the work for which this permit is issued, I Health & Safety Code, Section 2553a hould I store or handle hazardous shall not employ any person in any manner so as to become subject to the material. Additionally, should I use a uip nt or devices which emit hazardous air contaminants as defined by the Ba Area Air Quality Management District I Worker's Compensation laws of California. If, after making this certificate of will maintain compliance with the Cu ertin Municipa_l Code, Chapter 9.12 and exemption, I become subject to the Worker's Compensation provisions of the the Health &Safety Code, S ctio 2550 25533, and 25534. Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. Owner or authorized agent: APPLICANT CERTIFICATION / 4/5/2016 I certify that I have read this application and state that the above information is ND�ate: CONSTRUCTION L NDTNG 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 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. 1 understand my plans shall be used as public records. ed Signature Date 4/5/2016 Professional Professsional e CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20153 JOHN DR CONTRACTOR: ALPS CONSTRUCTION & PERMIT NO: 15080195 REMODELING OWNER'S NAME: MCLE,OD DAVID A AND MOKRZYCKI MARIA 1011 S DE ANZA BLVD DATE ISSUED: 11/12/2015 OWNER'S PHONE:, 6502796540 SAN JOSE, CA 95129 PHONE NO: (408) 898-6474 ` LC ®� IENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL ❑ ❑ License Class ` Lic. # ® �> 3 ADD 581 S.F. TO FRONT TO CREATE 2 (N) BEDROOMS & 1 (1) BATHROOM. REPLACE 2 (E) WINDOWS j Contractor M `S (o!S141A Date `i — 12 XG [CD 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 ceitificate of consent to self-insure for Worker's Compensation,' as provided for by Section 3700 of the Labor Code, for the Sq. Ft Floor Area: Valuation: $120000 -performance of the work for which this permit is issued. ave 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 . ' " , APN Number: 36933038.00 Occupancy Type: APPLICANT CERTIFICATION I certifythat I have read this, application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED 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 WITHIN 180 DAYS OF PERMIT ISSUANCE OR upon the above mentioned property for inspection purposes. (We) agree to save 180 FROMLASTC LED INSP C ION. indemnifyand keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses City in the IS which may accrue against said consequence of granting of this permit. Addition y, the applicant understands and will comply Issued by:�` `" Date: with all non-poi 'sourIcer 1 s per the upertino Municipal Code, Section a RE-ROOFS: i% Signature J Date ._ I Z— � 7 14—t2--/01075 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. ❑ OWNER-BUILDER ECLARATION ' 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, will do thef work, `and the structure is not intended or offered for sale (Sec.7044, Business & Professions Coded , I, as owner of the, property, am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project (Se6.7044, Business & Professions Code). I 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 declarations Health & Safety Code, Section 25532(a) 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. ode, Chapter 9.12 and I have andiwill maintain Workers Compensation Insurance, as provided for by the Health & Safety Code,-Sections 255 ,and 34. Section 3700 of the Labor Code, for the performance of the work for which this T f Owner or authorized agent: Date: 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 Compensatron'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 I hereby affirm that there is a construction lending agency for the performance of forthwith comply wft i 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 - indemnify and keep harmiless the City of Cupertino against liabilities, judgments, , ARCHITECTS DECLARATION 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 this permit. Additionally, the applicant understands and will comply with ap'r'on-point source regulations per the Cupertino Municipal Code, Section Licensed Professional 9.18. ,. Signatures Date CUPERTINO CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildinq(a)cupertino.org ISD�61q� ❑ NEW CONSTRUCTION 9 ADDITION ❑ ALTERATION / TI ❑ REVISION /DEFERRED ORIGINAL PERMIT il PROJECT ADDRESS APN 4 3( - 3 3-a33 OWNER NAME �J ' `_ /� (j (7a'y_ `HONE all STREET ADDRESS ry „ m vaa r( eCAG� 53 11 (%J 0 CITY, STATE, Z;IPP elpe"I_ ne) ,V t p FAX (� y6 CONTACT NAME /6 1. L PHONE ®1 t f _ E-MAIL _ STREET ADDRESS to5.YiZfil�V(I�l.�y CITY, STATE, ZIP FAX ❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT VkCONTRACTop, ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME 11 S S i ?C p J� LICENSE NUMBERQn/ LICENSE TYPE BUS. LIC # COMPANY NAME n /l, Cil S' 1(Y (ATC JQ E-MAIL d Ct' S _CTM A_(tAC_ PeoM L) CA FAX STREET ADDRESS /d (I S . OpePr,A Za V31k p 4 CITY, STATE, ZIP 37.03 e C ��2 PHONE `TQ 8 1-0110 I 1 C3�+ ARCHITECT/ENGINEERNAME LICENSE NUMBER BUS. LIC 9 COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,. STATE, ZIP PHONE DESCRIPTION OF WORK �'�'I 4raoo, lncPra91`f1 ' ®� ),aiASe Ar o,4 1&ec? 2 a4,/ iM �7tiS�l S�•m2 �%Ze S�+ne �s+CCc'��iiYi 1'n G°'I'aC:� EXISTING USE PROPOSED USE CONSTR TYPE # STORIES - _ USE TYPE OCC. 1 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 DECFJPORCH AREA GARAGE AREA: DETACH ❑ ATTACH # DWELLINGUNITS: IS. A SECOND UNIT []YES SECOND STORY ❑.YES. BEING ADDED? ❑ NO ADDITION? []NO PRE -APPLICATION [I YES IF YES, PROVIDE COPY OF IS THE BLDG AN 11 YES TOTAL VALUATION: PLANNINGAPPL# ❑NO PLANNING APPROVAL LETTER - EICHLERHOME? NO r _ ❑ a 1 By my signature below, I certify to each of the following: I am the property owner or author' age act on the property owner's behalf. I have read this application and the information I have provid 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 b istruction. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes. Date: Q 2,0 Signature of Applicant/Agent: ,G SUPPLEMENTAL INFORMA ON REQUIRED _ New SFD or Multifamily dwellings: Apply for demolition permit for AVER THliCOUNTERo NO BUIIDINGPLANREVIEw existing building(s). Demolition permit is required prior to issuance of building permit for new building. D 'ExPRss ❑ rr nNlvHicxLAar�iEw r 1] Commercial Bldgs: Provide a completed Hazardous Materials Disclosure STANDARD ruBLlewoRxs _ form if any Hazardous Materials are being used as part of this project. Copy of Planning Approval Letter or Meeting with Planning prior to ".MAJOR � ��'^ � SAl�'TTAR�SER'ERDISTRICT � _ submittal of Building Permit application. �� " t s ...'EIITVIRONMENTAYiHEALT17 �•* �`�,,':; BldgApp_2011.doc revised 06/21/11 CITY OF CUPERTINO FM -7 FEE ESTIMATOR - BUILDING DIVISION ADDRESS: 20153 JOHN DRQ APN: 369 33 038 BP#: DATE: 08/27/2015 REVIEWED BY: MELISSA *VALUATION: $120,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Addition PRIMARY USE.: SFD or Duplex 2nd Unit? OTC.? Yes ' No 0 Yes ®No PENTAMATION PERMIT TYPE: 1 R3SFDADD WORK ADD 581 S.F. TO FRONT TO CREATE 2 N BEDROOMS & 1 N BATHROOM. REPLACE 2 E SCOPE WINDOWS $0.00 OCCUPANCY TYPE: TYPE OF CONSTR. FLR AREA s.E PC FEES PC FEE ID BP FEES BP FEE ID R-3 (Custom) II-B,111-B,IV,V-B 581 $2,654.00 IR3PLNCK $1,666.00 IR3INSP PME Plan Check: $0.00 Permit Fee: $1,666.00 Suppl. Insp. Fee:Q Reg. Q OT 0.0 hrs $0.00 PME Unit Fee; $0.00 PME Permit Fee: $0.00 TOTALS: 581 $2,654.00 - $1,666.00 L 0 0 Work Without Permit? 0 Yes No $0.00 Advanced Planning Fee: IPLLONGR :-leeh, _Plana CheckPlumb. Non Check Elee. flan Cheeks Alech, Per°rnit Fee: Plum. Permit lice: Elec. Permittee: Other alech. Insp. Other Plumb Imp. Other- Elec. Insp. Wech. hup, Fee: Plupnb. Im}r..T'ee: E`l'C. Insp. I< :e: NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.). These fees are based on the Prelimina information available and are only an estimate. Contact the De t or addn'l in o. FEE ITEMS (Fee Resolution 11-053 Eff. 711113) FEE QTY/FEE MISC ITEMS Plan Check Fee: $2,654.00 = # $431.00 Window / Sliding Glass Door I WINREP Replacement Supp/. PC Fee; Reg. 0 OT 0.0 hr s $0.00 PME Plan Check: $0.00 Permit Fee: $1,666.00 Suppl. Insp. Fee:Q Reg. Q OT 0.0 hrs $0.00 PME Unit Fee; $0.00 PME Permit Fee: $0.00 Construction Tov: Administrative .Fee: L 0 0 Work Without Permit? 0 Yes No $0.00 Advanced Planning Fee: IPLLONGR $81.34 Select a Non -Residential Building or Structure 0 i Iraml Documentation Fees: Strong Motion. Fee: IBSEISMICR $15.60 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $5.00 y _ SUBT+(AL $4,421.94 $431.00_ TOALF $4,852.94 Revised: 07/02/2015 CUPERTINO 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: Z D % S- c, To�.'�> .-' PERMIT # l 5-b 60 l -15 OWNER'S NAME: IrA&.rcw 1!ti f PHONE # 4D B LIC�\ GENERAL CONTRACTOR:—De— BUSINESS LICENSE # 3 I $ l ADDRESS: (oLLS OF. CITY/ZIPCODE: *Our municipal code requires all busi$esses working in the city to have a City of Cupertino 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 Date Please check applicable subcontractors and complete the following information: V SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing S��cL Cou►c.r•e� Z�OgS� Electrical �',r•�S�- ��-ecru -Z,c.S Excavation Fencing Flooring / Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting / Wallpaper Paving Plastering Plumbing �tv ��h� 3 3' Z Roofing �Grco tZ.oe�; Z \Z t-1 Septic Tank Sheet Metal Sheet Rock Tile Owner / Contractor Signature 00/50 l to ate o CUPERTINO STATEMENT OF SPECIAL INSPECTIONS, 2013 CBC COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building Cc�cu perti no. org I tn r .. _ . _L..9................................ Date ...... AP B'# ADDRESS Inspection Agency / Insp ctor Name: 1 x0y L . . ...........��, Si nature ... .i7.Y. 36 6 S62,0195' OwnerN(.=..7.PPN..>_Q..kMO4�,r.' tC ....Mi '�.. ............... Contractor....................................................................................................... Address...Z.=.I.A5.3t....�.....p.Q................................................... Address ........................................................................................................... City/St.Q..99.Frr1..�4.0.......... Zip ...........................Phone..................... City/St ................................................. Zip .................. .Phone ........................ Applicant.........................................................................................................Engineer rchitect Rk+F*�1•kN �.. it.%1?S!a�4 4s.....lt-� ................ Address........................................................................................................... Address.lg...! �1�tLN..ANS.............................................. City/St............................................. Zip ........................... Phone..................... Cit /St ShN. �sre ... Zi S!24 Phon 46$)37 PROJECT DESCRIPTION: � -72 This "STATEMENT OF SPECIAL INSPECTIONS" is submitted in fulfillment of the requirements of CBC Sections 1704 and 1705. This form is structured after and used by permission from the Structural Engineer Association of Northern California's (SEAONC) mode statement of Special Inspections. Also, included with this form is the following: ❑ "LIST OF SPECIAL INSPECTION AGENCIES (page 2). A list of testing agencies and other special inspectors that will be retained to conduct the tests and inspections for this project ❑ "SCHEDULE OF SPECIAL INSPECTION" (page 3 - 6). The Schedule of Special Inspections summarizes the Special Inspections and tests required. Special Ins nsMve sled special inspection requirements. Any additional to an i re app cifi tions shall also be performed. ®®® Special Inspections and Testing will be performed in accordance with the approved plans and specifications, this statement and CBC Sections 1704, 1705, 1706, 1707, and 1708. Interim reports will be submitted to the Building Official and the Registered Design Professional in Responsible Charge in accordance with CBC Section 1704.1.2. A Final Report of Special Inspections documenting required Special Inspections, testing and correction of any discrepancies noted in the inspections shall be submitted prior to issuance of a Certificate of Use and Oc�4 12 The �inal Report will document: TEVIV • Required special inspections. • Correction of discrepancies noted in inspections. The Owner recognizes his or her obligation to ensure that the construction complies with the approved permit documents and to implement this program of special inspections. In partial fulfillment of these obligations the Qwner will retaiq a directly pay for the Special Inspections as required in CBC Section 1704.1. �''c This plan has been developed with the understanding that the Building Official y tf� au;lc"ng DOPatment r�r • Review and approve the qualifications of the Special Inspectors who vyIkE`f6rm the inspections. • Monitor special inspection activities on the job site to assure that the S` p'ecia'Mispectors are qualified and are performing their duties as called for in this Statement of Special Inspection. Review submitted inspection reports. • • Perform inspections as required by the local building code. VIEVVL� Frj)+I�OMPLIAN � CE . �Fsrlinar,�F?t'1 R I have read and agree to comply with the terms and conditions of this Uater hie —01' �;,✓ Prepared By:, Project Engineer LIArchitect Registered De§i `n Professional in Charge f~'" Signat ........... l ...................Lic.# .. _ . _L..9................................ Date ...... O ner Na e4ZAut ,wrization Sin .. ...... ..` ...............................Date:....... Inspection Agency / Insp ctor Name: 1 x0y L . . ...........��, Si nature ... .i7.Y. /...... Lic.# ....................................... Date: y3q. Building Official of designee: Signature .................... ..............:.............. Date:...7.I�(0... O SpecialnspectionForm_2012.doc revised 09/06/12 'OQO LIST OF SPECIAL INSPECTION AGENCIES APPROVAL OF SPECIAL INSPECTORS: Each special inspection agency, testing facility, and special inspector shall be recognized by the Building Official prior to performing any duties. Special Inspection agency's listed on this form must be pre -approved and listed on Cupertino's approved Special Inspector's list. Special inspectors shall carry approved identification when performing the functions of a special inspector. Identification cards shall follow the criteria set by the California Council of Testing and Inspection Agencies. No personnel changes shall be made without first obtaining the approval of the Building Official. Any unauthorized personnel changes may result in a "Stop Work Order' and possible permit revocation. To be pre- approved by the City of Cupertino, refer to the SPECIAL INSPECTION CRITERIA handout. Please allow two weeks to complete the application process. I he tollowing are the testing and special Inspection agencies that will be retained to conduct tests and inspection on this proiect EXPERTISE FIRM / INSPECTOR INFORMATION * 1. Special Inspection (except for Firm.....................................................................Addr......................................................................................... geotechnical) City.......................................................................................................... State .......................Zip ...................... Telephone...................................... Fax ............................................ Email......................................................... 2. Material Testing Firm.....................................................................Addr......................................................................................... City.......................................................................................................... State .......................Zip ...................... Telephone.......................................Fax............................................ Email......................................................... 3. Geotechnical Inspections Firm.....................................................................Addr......................................................................................... City.......................................................................................................... State .......................Zip ...................... Telephone...................................... Fax ............................................ Email......................................................... 4. Other: Firm.....................................................................Addr......................................................................................... City.......................................................................................................... State .......................Zip ...................... Telephone...................................... Fax ............................................ Email......................................................... *All agencies specified on this form must be pre -approved and listed on the City of Cupertino's Approved Special Inspector's List. SEISMIC REQUIREMENTS (Section 1705.3.6) Description of seismic -force -resisting system and designated seismic systems subject to special inspections as per Section 1705.3: The extent of the seismic -force -resisting system is defined in more detail in the construction documents. WIND REQUIREMENTS Section 1705.4.1 Description of main wind -force -resisting system and designated wind resisting components subject to special inspections in accordance with Section 1705.4.2: The extent of the main wind -force -resisting system and wind resisting components is defined in more detail in the construction documents. SpecialnspectionForrrr 2012.doc revised 09/06/12 SCHEDULE OF SPECIAL INSPECTION SITE APN BP# ADDRESS PROJECT DESCRIPTION: Notation Used in Table: Column headers C Indicates continuous inspection is required. P Indicates periodic inspections are required. The notes and/or contract documents should clarify. Box entries: X Is placed in the appropriate column to denote either "C" continuous or "P" periodic inspections. --- Denotes an activity that is either a one-time activity or one whose frequency is defined in some other manner. Additional detail regarding inspections and tests are provided in the project specifications or notes on the drawings. VERIFICATION AND INSPECTION C p REFERENCED STANDARD IBC REFERENCE INSPECTION OF FABRICATORS 1. ❑ Inspect fabricator's fabrication and quality control _ _ 1704.3 procedures. INSPECTION OF STEEL 1. Material verification of high-strength bolts, nuts and washers. ❑ Identification marking to conform to ASTM stds AISC 360, specified in the approved construction documents. --- X Section A3.3 and applicable ASTM material standards ❑ Inspect fabricator's fabrication and quality control procedures. --- X --- 2. Inspection of high-strength bolting: ❑ Snug -tight joints. --- X ❑ Pretensioned and slip -critical joints using turn -of -nut with matchmarking, twist -off bolt or direct tension --- X AISC 360, indicator methods of installation. 1704.3.3 Section M2.5 ❑ Pretensioned and slip -critical joints using turn -of -nut without matchmarking or calibrated wrench methods X --- of installation. 3. Material verification of structural steel and cold -formed steel deck. ❑ For structural steel, identification markings to conform_ X AISC 360, to AISC 360. _ Section M2.5 ❑ For other steel, identification markings to conform to Applicable ASTM ASTM standards specified in the approved --- X construction documents. material standards ❑ Manufacturer's certified test reports. --- X SpeeialnspectionForrrn_2012.doc revised 09/06/12 VERIFICATION AND INSPECTIONC C p REFERENCED STANDARD IBC REFERENCE 4. Material verification of weld filler materials: ❑ Identification marking to conform to AWS specification in the approved construction documents. --- X AISC 360, Section A3.5 and applicable AWS A5 documents 1704.3 ❑ Manufacturer's certificate of compliance required. --- X --- --- 5. Inspection of welding: a. Structural steel and cold -formed steel deck: ❑ Complete and partial joint penetration groove welds. X --- AWS D1.1 1704.3.1 ❑ Multipass fillet welds. X --- ❑ Single -pass fillet welds > 5/16" X --- ❑ Plug and slot welds. X --- ❑ Single -pass fillet welds — 5/16" --- X ❑ Floor and roof deck welds. --- X AWS D1.3 b. Reinforcing steel: ❑ Verification of weldability of reinforcing steel other than ASTM A 706. - - X AWS D1.4 ACI 318: Section 3.5.2 ❑ Reinforcing steel resisting flexural and axial forces in intermediate and special moment frames, and boundary elements of special structural walls of concrete and shear reinforcement. X ___ ❑ Shear reinforcement. X --- ❑ Other reinforcing steel. --- X 6. Inspection of steel frame joints details for compliance: ❑ Details such as bracing and stiffening. --- X --- 1704.3.2 ❑ Member locations. --- X ❑ Application of joint details at each connection. --- X VERIFICATION AND INSPECTION C P REFERENCED STANDARD FFBC IREFERENCE INSPECTION OF WELDING 1. ❑ Welded studs when used for structural diaphragms. --- X --- 1704.3 2. XWelding of cold -formed steel framing members. --- X 3. ❑ Welding of stairs and railing systems. --- X Specialnspectionf'oi•m_2012.doc revised 09106/12 VERIFICATION AND INSPECTION C p REFERENCED TIBC STANDARD REFERENCE INSPECTION OF CONCRETE 1. ❑ Inspection of reinforcing steel, including prestressing --- X ACI 318: 3.5, 7.1-7.7 1913.4 tendons and placement. 2. ❑ Inspection of reinforcing steel welding in accordance AWS D1.4 ACI 318: with Table 1704.3 Item 5b. 3.5.2 3. ❑ Inspection of bolts to be installed in concrete prior to and during placement of concrete where allowable X ACI 318: 8.1.3, 1911.5, 1912.1 loads have been increased or where strength design 21.2.8 is used. 4. ❑ Inspection of anchors installed in hardened concrete. --- X ACI 318: 1912.1 5. ❑ Verifying use of required design mix. 1904.2.2,1913.2, --- X ACI 318: 1913.3 6. ❑ At time fresh concrete is sampled to fabricate ASTM C 172 specimens for strength tests, perform slump and air X --- ASTM C 31 1913.10 content tests and determine the temperature of the concrete. ACI 318: 5.6, 5.8 7. ❑ Inspection of concrete and shotcrete placement for X --- ACI 318: 5.9, 5.10 1913.6, 1913.7, proper application techniques. 1913.8 8. ❑ Inspection for maintenance of specified curing --- X ACI 318: 5.11-5.13 1913.9 temperature and techniques. 9. Inspection of prestressed concrete: ❑ Application of prestressing forces. X --- ACI 318:18.20 ❑ Grouting of bonded prestressing tendons in the X --- ACI 318: 18.18.4 seismic force -resisting system. 10. ❑ Erection of precast concrete members. --- X ACI 318: Ch. 16 --- 11. ❑ Verification of in-situ concrete strength, prior to stressing of tendons in posttensioned concrete and --- X ACI 318: 6.2 --- prior to removal of shores and forms from beams and structural slabs. 12. ❑ Inspect formwork for shape, location, and dimensions X ACI 318: 6.6.1 --- of the concrete member being formed. 13. ❑ Bolts Installed in Existing Masonry or Concrete ❑ Direct tension testing of existing anchors. --- X See ICC ES Reports form special inspection requirements for proprietary ❑ Direct tension testing of new bolts. --- X ❑ Torque testing of new bolts. ___ X products ❑ Prequalification test for bolts and other types of X anchors. 14. ❑ Other: SpecialnspectionForm_2012.doc revised 09/06/12 SpecinlnspectionForm_2012.doc revised 09/06/12 REFERENCE FOR CRITERIA VERIFICATION AND INSPECTION C P IBC TMS 402/ACI TMS 402/ACI SECTION I 530/ASCE 5 530/ASCE 6 INSPECTION OF LEVEL 1 MASONRY 1. ❑ Compliance with required inspection provisions of the construction documents and the approved --- X --- --- Art. 1.5 submittals shall be verified. 2. ❑ Verification of fm and fAAc prior to construction ___ X ___ __- Art. 1.413 except where specifically exempted by this code. 3. ❑ Verification of slump flow and VSI as delivered to X ___ ___ Art. 1.5B.1.b.3 the site for self consolidating grout. 4. As masonry construction begins, the following shall be verified to ensure compliance: ❑ Proportions of site -prepared mortar. --- X --- --- Art. 2.6A ❑ Construction of mortar joints. --- X --- --- Art.3.313 ❑ Location of reinforcement, connectors, ___ X ___ _-_ Art. 3.4, 3.6A prestressing tendons, and anchorages. ❑ Prestressing technique. --- X --- --- Art. 3.613 ❑ Grade and size of prestressing tendons and ""- X --- --- Art. 2.413, 2.4H anchorages. 5. During construction the inspection program shall verify: ❑ Size and location of structural elements. --- X --- --- Art. 3.3F ❑ Type, size, and location of anchors, including Sec. 1.2.2(e), other details of anchorage of masonry to --- X "' 1.16.1 structural members, frames or other construction. ❑ Specified size, grade, and type of reinforcement, anchor bolts, prestressing tendons and --- X --- Sec. 1.15 Art. 2.4, 3.4 anchorages. ❑ Welding of reinforcing bars. X --- --- • Preparation, construction and protection of masonry during cold weather (temperature below ___ X Sec. 2104.3, ___ Art. 1.8C, 1.8D 40 degrees F) or hot weather (temperature above 2104.4 90 degrees F). ❑ Application and measurement of prestressingX _ _ ___ Art. 3.613 force. 6. Prior to grouting the following shall be verified to ensure compliance: ❑ Grout space is clean. --- X --- --- Art. 3.21) ❑ Placement of reinforcement and connectors and ___ X --_ Sec. 1.3 Art. 3.4 prestressing tendons and anchorages. ❑ Proportions of site -prepared grout and X prestressing grout for bonded tendons. _-_ __- --- Art. 2.613 ❑ Construction of mortar joints. --- X --- --- Art. 3.36 7. Grout placement: ❑ Grout placement shall be verified ensure compliance. X ___ ___ --- Art. 3.5 ❑ Observe grouting of prestressing bonded tendons. X ___ ___ ___ Art 3.6C SpecinlnspectionForm_2012.doc revised 09/06/12 SpecinlnspectionForm_2012.doc revised 09/06/12 REFERENCE FOR CRITERIA VERIFICATION AND INSPECTION C P IBC TMS 402/ACI TMS 402/ACI SECTION 530/ASCE 5 530/ASCE 6 8. ❑ Preparation of any required grout specimens, Sec. mortar specimens, and/or prisms shall be --- X 2105.2.2, --- Art. 1.4 observed. 2105.3 INSPECTION OF LEVEL 2 MASONRY 1. ❑ Compliance with required inspection provisions of the construction documents and the approved --- X --- --- Art. 1.5 submittals. 2. ❑ Verification of fm and faac prior to construction and for every 5,000 square feet during --- X --- --- Art. 1.46 construction. 3. ❑ Verification of proportions of materials in premixed or preblended mortar and grout as --- X --- --- Art. 1.56 delivered to the site. 4. ❑ Verification of slump flow and VSI as delivered to X --- _ --- Art. 1.513.1.b.3 the site for self consolidating rout. 5. The following shall be verified to ensure compliance: ❑ Proportions of site -prepared mortar, grout, and --- X --- --- Art. 2.6A prestressing grout for bonded tendons. ❑ Placement of masonry units and construction of --- X --- --- Art. 3.36 mortar joints. ❑ Placement of reinforcement, connectors and --- X --- Sec. 1.15 Art. 3.4, 3.6A prestressing tendons and anchorages. ❑ Grout space prior to grouting. X --- --- --- Art. 3.2D ❑ Placement of grout. X --- --- --- Art. 3.5 ❑ Placement of prestressing grout. X --- --- --- Art. 3.6C ❑ Size and location of structural elements. --- X --- --- Art. 3.317 ❑ Type, size, and location of anchors, including other details of anchorage of masonry to X --- --- Sec.1.2.2(e) --- structural members, frames and other construction. ❑ Specified size, grade, and type of reinforcement, anchor bolts, prestressing tendons and --- X --- Sec. 1.15 Art. 2.4, 3.4 anchorages. ❑ Welding of reinforcing bars. X --- Sec. 2.1.9.7.2, --- 3.3.3.4 (b) ❑ Preparation, construction, and protection of masonry during cold weather (temperature below ___ X Sec. 2104.3, --- Art. 1.8C, 1.8D 40 degrees F) or hot weather (temperature above 2104.4 90 degrees F). ❑ Application and measurement of prestressing X --- --- --- Art. 3.66 force. 6. ❑ Preparation of any required grout specimens, Sec. mortar specimens, and/or prisms shall be X --- 2105.2.2, --- Art. 1.4 observed. 2105.3 SpecinlnspectionForm_2012.doc revised 09/06/12 VERIFICATION AND INSPECTIONC p REFERENCED IBC STANDARD REFERENCE INSPECTION OF WOOD 1. ❑ Inspect prefabricated wood structural elements and assemblies in accordance with Section 1704.2. --- 1704.6 2. ❑ Inspect site built assemblies. --- --- 3. Inspect high -load diaphragms: ❑ Verify grade and thickness of sheathing. --- --- ❑ Verify nominal size of framing members at adjoining panel edges. _ --- 1704.6.1 ❑ Verify nail or staple diameter and length, --- --- ❑ Verify number of fastener lines, --- 0 Verify spacing between fasteners in each line and at edge margins. 4. ❑ Metal -plate -connected wood trusses spanning 60 feet or greater: Verify temporary installation restraint/bracing and the permanent individual truss --- X --- 1704.6.2 member bracing are installed in accordance with the approved truss submittal package. REQUIRED VERIFICATION AND INSPECTION OF SOIL 1. ❑ Verify materials below footings are adequate to achieve the desired bearing capacity. X 2. ❑ Verify excavations are extended to proper depth and X have reached proper material. 3. ❑ Perform classification and testing of compacted fill X materials. --- Table 1704.7 4. ❑ Verify use of proper materials, densities and lift thicknesses during placement and compaction of X --- compacted fill. 5. ❑ Prior to placement of compacted fill, observe subgrade X and verify that site has been prepared properly. REQUIRED VERIFICATION AND INSPECTION OF DEEP DRIVEN FOUNDATION ELEMENTS 1. ❑ Verify element materials, sizes and lengths comply X with the requirements. 2. ❑ Determine capacities of test elements and conduct X additional load tests, as required. 3. ❑ Observe driving operations and maintain complete X and accurate records for each element. 4. ❑ Verify locations of piles and their plumbness, confirm type and size of hammer, record number of blows per --- Table 1704.8 foot of penetration, determine required penetrations to X --- achieve design capacity, record tip and butt elevations and document any damage to foundation element. 5. ❑ For steel elements, perform additional inspections in accordance with Section 1704.3. 6. ❑ For concrete elements and concrete filled elements, perform additional inspections in accordance with --- --- Section 1704.4. SpecrnlnspectionForm_ 2012.doc revised 09/06/12 VERIFICATION AND INSPECTION C P REFERENCED STANDARD IBC REFERENCE 7. ❑ For specialty piles, perform additional inspections as determined by the registered design professional in --- --- --- Table 1704.8 responsible charge. REQUIRED VERIFICATION AND INSPECTION OF CAST -IN-PLACE DEEP FOUNDATION ELEMENTS 1 ❑ Observe drilling operations and maintain complete and X accurate records for each element. 2. ❑ Verify placement locations and plumbness, confirm element diameters, bell diameters (if applicable), lengths, embedment into bedrock (if applicable), and X --- --- Table 1704.9 adequate end -bearing strata capacity. Record concrete or grout volumes. 3. ❑ For concrete elements, perform additional inspections in accordance with Section 1704.4. HELICAL PILE FOUNDATIONS 1. ❑ Record installation equipment used, pile dimensions, X --- --- 1704.10 tip elevations, final depth, final installation torque. SPRAYED FIRE-RESISTANT MATERIALS Physical and visual tests 1. Condition of substrates. ❑ Inspect surface for accordance with the approved fire - resistance design and the approved manufacturer's --- --- written instructions. ❑ Verify minimum ambient temperature before and after X application. --- 1704.12.1 ❑ Verify ventilation of area during and after application. --- X 2. ❑ Measure average thickness per ASTM E605 and --- --- Section 1704.12.4. S 3. ❑ Verify density of material for conformance with the approved fire-resistant design and ASTM E605. (Ref. --- Section 1704.12.5) 4. ❑ Test cohesive/adhesive bond strength per Section 1704.12.6. 5. ❑ Condition of finished application. MISCELLANEOUS 1. Mastic and Intumescent Fire -Resistant Coating. --- --- --- 1704.13 2. Exterior Insulation and Finish Systems (EIFS). Water - resistive barrier coating when installed over a sheathing --- --- --- 1704.14 substrate. 3. Special Cases --- --- --- 1704.15 4. Smoke Control System --- --- --- 1704.16 5. Seismic Resistance ❑ Suspended ceiling systems and their anchorage. --- --- --- 1705.3 [4.3] SpecialnspectionForin 2012.doc revised 09/06112 VERIFICATION AND INSPECTIONC P REFERENCED IBC STANDARD REFERENCE 6. Wind Resistance ❑ Roof cladding and roof framing connections. --- --- --- ❑ Wall connections to roof and floor diaphragms and framing. --- --- 11 Roof Roof and floor diaphragm systems, including collectors, drag struts and boundary elements. ❑ Vertical wind -force -resisting systems, including braced frames, moment frames, and shear walls. ❑ Wind -force -resisting system connections to the foundation. -- --- --- ❑ Fabrication and installation of systems or components required to meet the impact resistance requirements --- --- --- of Section 1609.1.2. SPECIAL INSPECTION FOR WIND REQUIREMENTS 1. Structural Wood ❑ Inspect field gluing operations of elements of the main X wind -force -resisting system. --- 1706.2 ❑ Inspect nailing, bolting, anchoring, and other fastening of components within the main windforce-resisting X system, including wood shear walls, wood diaphragms, drag struts, braces and hold-downs. 2. Cold -Formed Steel Framing ❑ Welding of elements of the main wind -force -resisting system. X ❑ Inspection of screw attachments, bolting, anchoring, and other fastening of components within the main --- 1706.3 wind -force -resisting system including shear walls, --- X braces, diaphragms, collectors (drag struts) and hold- downs. 3. Wind -resisting components ❑ Roof cladding. --- X --- 1706.4 ❑ Wall cladding. --- X SPECIAL INSPECTIONS FOR SEISMIC RESISTANCE 1. ❑ Special inspection for welding in accordance with the X 7- quality assurance plan requirements of AISC 341. 1707.2 2. Structural Wood ❑ Inspect field gluing operations of elements of the X seismic -force -resisting system. ❑ Inspect nailing, bolting, anchoring, and other fastening of components within the seismic -force -resisting 1707.3 system, including wood shear walls, wood --- X diaphragms, drag struts, braces, shear panels and hold-downs. 3. Cold -Formed steel light -frame construction ❑ Welding of elements of the seismic -force -resisting system. _ X 1707.4 SpecinlnspeclionForn:_2012.doc revised 09/06/12 ❑ Inspection of screw attachments, bolting, anchoring, and other fastening of components within the seismic- X force -resisting system including shear walls, braces, diaphragms, collectors (drag struts) and hold-downs. 4. Storage racks and access floors ❑ Anchorage of storage racks 8 feet or greater in height X 1707.5 and access floors. 5. Architectural components ❑ Inspect erection and fastening of exterior cladding weighing more than 5 psf and higher than 30 feet --- X above grade or walking surface. ❑ Inspect erection and fastening of veneer weighing more than 5 psf.and higher than 30 feet above grade --- X or walking surface. --- 1707.6 ❑ Inspect erection and fastening of all exterior non- bearing walls higher than 30 feet above grade or --- X walking surface. ❑ Inspect erection and fastening of all interior non- bearing walls weighing more than 15 psf and higher --- X than 30 feet above grade or walking surface. 6. Mechanical and Electrical Components ❑ Inspect anchorage of electrical equipment for X emergency or stand-by power systems. ❑ Inspect anchorage of non -emergency electrical X equipment. ❑ Inspect installation of piping systems and associated mechanical units carrying flammable, combustible, or --- X --- 1707.7 highly toxic contents. ❑ Inspect installation of HVAC ductwork that contains X hazardous materials. ❑ Inspect installation of vibration isolation systems X where required by Section 1707.7. 7. ❑ Verify that the equipment label and anchorage or mounting conforms to the certificate of compliance ___ 1707.8 when mechanical and electrical equipment must be seismically qualified. 8. ❑ Seismic isolation system: Inspection of isolation --- X --- 1707.9 system per ASCE 7 — Section 17.2.4.8 9. ❑ Obtain mill certificates for reinforcing steel, verify compliance with approved construction documents, --- --- --- 1708.2 and verify steel supplied corresponds to certificate. 10. ❑ Structural Steel: Invoke the QAP Quality Assurance 1708.3 requirements in AISC 341. ___ 11. ❑ Obtain certificate that equipment has been seismically qualified. __- 1708.4 12. ❑ Obtain system tests as required by ASCE 7 Section 17.8. --- --- 1708.5 SpecinlnspectionForin_2012.doc revised 09/06/12 CUPERTINO STATEMENT OF SPECIAL INSPECTIONS, 2013 CBC COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building okupertino.org SITE ADDRESS APN 369-33 d �� BP#l�o C, U ` a 7,1 owner. ... V�.................tcf .........PL4. 4.!r.J'&...... ff 1 .................................. ..... ontractor .:....t.. ....L...... ^-_ ............................ l..I . Address.. b :...!'1►1.7F.L......_..y. y [Add,r',ets..s `J ,` �( �.% .......... Zip..... .54)1...��. Phone.. v. �i Zii _.:..................... . ......... Building Official or designee: .....................................r........ Lic.............. p.. ... ... ........... Phone ...Yp.�Y Applicant ......................................................................................................... Engineer/Architect.I-6- rl /2!!/�.. Address........................................................................................................... Address............................................................................................. City/St............................................. Zip ........................... Phone ..................... City/St.......................................... Zip p ............... Phone.................... PROJECT D SC i 'fIPTION: t This "STATEMENT OF SPECIAL INSPECTIONS" is submitted in fulfillment of the requirements of CBC Sections 1704 and 1705. This form is structured after and used by permission from the Structural Engineer Association of Northern California's (SEAONC) mode statement of Special Inspections. Also, included with this form is the following: ❑ "LIST OF SPECIAL INSPECTION AGENCIES (page 2). A list of testing agencies and other special inspectors that will be retained to conduct the tests and inspections for this project ❑ "SCHEDULE OF SPECIAL INSPECTION" (page 3 - 6). The Schedule of Special Inspections summarizes the Special Inspections and tests required. Special Inspectors will refer to the approved plans and specifications for detailed special inspection requirements. Any *Pp. nal tests and inspections required by the approved plans and specifications shall also be performed. ,41 Special Inspections and Testing will be performed t rdance with the approved plans and specifications, this statement and CBC Sections 1704, 1705, 1706, 1707, and 1708. Interim rill be submitted to the Building Official and the Registered Design Professional in Responsible ChalAin accordance withl�ection 1704.1.2. A Final Report of Special Inspections cumenting required Special Inspections, testing and correction of any discrepancies noted in the inspections shall be submitted prior ssuance of a Certificate of Use and Occupancy (Section 1704.1.2). The Final Report will document: • Required special inspections. • Correction of discrepancies noted in inspections. ��'� The Owner recognizes his or her obligation to ensure that the construction complies with the proved pe 1 cuments and to implement this program of special inspections. In partial fulfillment of these obligkons, the Owner will rets n� directly pay for the Special Inspections as required in CBC Section 1704.1. This plan has been developed with the understanding that the Building Official will: • Review and approve the qualifications of the Special Inspectors who will perform the inspections. • Monitor special inspection activities on the job site to assure that the Special Inspectors are qualified and are performing their duties as called for in this Statement of Special Inspection. • Review submitted inspection reports. • Perform inspections as required by the local building code. I have rP&rl and atrraa fn nmmnly Wifh fhc f— —4 --4W--- „t 41,; Prepared By: Project Engineer ❑ Architect Re istered Design Professional in Char e` ............ Lic.# ............... .s. ....... Date:.......................... Mal "hf L Signature ...1.'.f .:..!` �.�.I�.r..... � Inspection Age / Inspecto N e: / iasf�e(/�13T �A .............. . I ............. nature�....... Building Official or designee: .....................................r........ Lic.............. Dat../� Signature......................................................... Date:l.la� SpecialnspectionForm-2012.doc revised 09/06/12 167 LIST OF SPECIAL INSPECTION AGENCIES APPROVAL OF SPECIAL INSPECTORS: Each special inspection agency, testing facility, and special inspector shall be recognized by the Building Official prior to performing any duties. Special Inspection agency's listed on this form must be pre -approved and listed on Cupertino's approved Special Inspector's list. Special inspectors shall carry approved identification when performing the functions of a special inspector. Identification cards shall follow the criteria set by the California Council of Testing and Inspection Agencies. No personnel changes shall be made without first obtaining the approval of the Building Official. Any unauthorized personnel changes may result in a "Stop Work Order' and possible permit revocation. To be pre- approved by the City of Cupertino, refer to the SPECIAL INSPECTION CRITERIA handout. Please allow two weeks to complete the application process. The followinq are the testing ands ecial inspection a encies that will be retained to conduct t t d ,., UyJ ui w 0PVkA11cu vii ung Jural rnusr oe pre -approved and listed on the City of Cupertino's Approved Special Inspector's List. SEISMIC REQUIREMENTS (Section 1705.3.6) Description of seismic -force -resisting system and designated seismic systems subject to special inspections as per Section 1705.3: The extent of the seismic -force -resisting system is defined in more detail in the construction documents. WIND REQUIREMENTS Section 1705.4.1 Description of main wind -force -resisting system and designated wind resisting components subject to special inspections in accordance with Section 1705.4.2: The extent of the main wind -force -resisting system and wind resisting components is defined in more detail in the construction documents. SpecialnspectionForm_2012.doc revised 09/06/12 es an i s ns ection on this pLoject. EXPERTISE FIRM / INSPECTOR INFORMATION 1. Special Inspection (except for Firm ............. . ....................................................... Addr........................... geotechnical) City .............................................................. .......................................................................................................... State .......................Zi Telephone...................................... Fax ............................................ Email......................................................... 2. Material Testing Firm.....................................................................Addr......................................................................................... City.......................................................................................................... State .......................Zip ...................... Telephone.......................................Fax............................................ Email......................................................... 3. Geotechnical inspections Firm.....................................................................Addr......................................................................................... City.......................................................................................................... State .......................Zip ...................... Telephone...................................... Fax ............................................ Email......................................................... 4. Other: Firm.....................................................................Addr........................... ............................................................. City.......................................................................................................... Telephone...................................... Fax ............................................ State .......................Zip Email......................................................... ...................... *ell .� ,.:a..,a .�:_ e_ ,., UyJ ui w 0PVkA11cu vii ung Jural rnusr oe pre -approved and listed on the City of Cupertino's Approved Special Inspector's List. SEISMIC REQUIREMENTS (Section 1705.3.6) Description of seismic -force -resisting system and designated seismic systems subject to special inspections as per Section 1705.3: The extent of the seismic -force -resisting system is defined in more detail in the construction documents. WIND REQUIREMENTS Section 1705.4.1 Description of main wind -force -resisting system and designated wind resisting components subject to special inspections in accordance with Section 1705.4.2: The extent of the main wind -force -resisting system and wind resisting components is defined in more detail in the construction documents. SpecialnspectionForm_2012.doc revised 09/06/12 SCHEDULE OF SPECIAL INSPECTION SITE APN gp# ADDRESS -7 PROJECT DESCRIPTION: Notation Used in Table: Column headers: C Indicates continuous inspection is required. P Indicates periodic inspections are required. The notes and/or contract documents should clarify. Box entries: X Is placed in the appropriate column to denote either "C" continuous or "P" periodic inspections. --- Denotes an activity that is either a one-time activity or one whose frequency is defined in some other manner. Additional detail regarding inspections and tests are orovided in the nrnier:t cnPr-ificatinnc „r nmc — ++,o A,.,,.,,— VERIFICATION AND INSPECTION C P REFERENCED IBC REFERENCE STANDARD INSPECTION OF FABRICATORS 1. ❑ Inspect fabricator's fabrication and quality control procedures. I --- --- 1704.3 INSPECTION OF STEEL 1. Material verification of high-strength bolts, nuts and washers. ❑ Identification marking to conform to ASTM stds AISC 360, specified in the approved construction documents. X Section A3.3 and applicable ASTM material standards ❑ Inspect fabricator's fabrication and quality control procedures. --- X --- --- 2. Inspection of high-strength bolting: ❑ Snug -tight joints. --- X ❑ Pretensioned and slip -critical joints using turn -of -nut with matchmarking, twist -off bolt or direct tension --- X indicator methods of installation. AISC 360, Section M2.5 1704.3.3 ❑ Pretensioned and slip -critical joints using turn -of -nut without matchmarking or calibrated wrench methods X --- of installation. verification of structural steel and cold -formed steel deck. r3.Material ❑ For structural steel, identification markings to conformAISC 360, to AISC 360. ___ X Section M2.5 ❑ For other steel, identification markings to conform to ASTM standards specified in the approved --- X Applicable ASTM construction documents. material standards ❑ Manufacturer's certified test reports. --- X SpecialnspectionForm_2012.doc revised 09/06/12 VERIFICATION AND INSPECTION CJE:�REFERENCED P REFERENCED STANDARD IBCTANDARD REFERENCE 4. Material verification of weld filler materials: ❑ Identification marking to conform to AWS specification in the approved construction documents. --- X AISC 360, Section A3.5 and applicable AWS A5 documents 1704.3 ❑ Manufacturer's certificate of compliance required. --- X 3. ❑ Welding of stairs and railing systems. ___ 5. Inspection of welding: a. Structural steel and cold -formed steel deck: ❑ Complete and partial joint penetration groove welds. X --- AWS D1.1 1704.3.1 ❑ Multipass fillet welds. X --- ❑ Single -pass fillet welds > 5/16" X --- ❑ Plug and slot welds. X ___ ❑ Single -pass fillet welds <= 5/16" ___ X ❑ Floor and roof deck welds. --- X AWS D1.3 b. Reinforcing steel: ❑ Verification of weldability of reinforcing steel other than ASTM A 706. "- X D1.4 ACI 318: Section 3.5.2 --- ❑ Reinforcing steel resisting flexural and axial forces in intermediate and special moment frames, and boundary elements of special structural walls of concrete and shear reinforcement. XAWS ❑ Shear reinforcement. X --- ❑ Other reinforcing steel. ___ X 6. Inspection of steel frame joints details for compliance: ❑ Details such as bracing and stiffening. -__ X --- 1704.3.2 ❑ Member locations. --- X ❑ Application of joint details at each connection. --- X VERIFICATION AND INSPECTION:1 C P REFERENCED STANDARD IBC REFERENCE INSPECTION OF WELDING 1. ❑ Welded studs when used for structural diaphragms. --- X --- 1704.3 2. ❑ Welding of cold -formed steel framing members. --- X 3. ❑ Welding of stairs and railing systems. ___ X SpecialnspectionForm_2012.doc revised 09/06/12 VERIFICATION AND INSPECTION C P REFERENCED IBC ❑ Grouting of bonded prestressing tendons in the seismic force -resisting system. X --- STANDARD REFERENCE INSPECTION OF CONCRETE 1. ❑ Inspection of reinforcing steel, including prestressing X ACI 318: Ch. 16 -- 11. ❑ Verification of in-situ concrete strength, prior to stressing of tendons in posttensioned concrete and prior to removal of shores and forms from beams and structural slabs. tendons and placement. --- X ACI 318: 3.5, 7.1-7.7 1913.4 2. ❑ Inspection of reinforcing steel welding in accordance___ X ACI 318: 6.6.1 AWS D1.4 ACI 318: 13. ❑ Bolts Installed in Existing Masonry or Concrete with Table 1704.3 Item 5b. "- X 3.5.2 --- 3. ❑ Inspection of bolts to be installed in concrete prior to X ❑ Torque testing of new bolts. ___ X and during placement of concrete where allowable --- X ACI 318: 8.1.3, loads have been increased or where strength design X -- 21.2.8 1911.5, 1912.1 is used. 4. ❑ Inspection of anchors installed in hardened concrete. --- X ACI 318: 1912.1 5. ❑ Verifying use of required design mix. 1904.2.2,1913.2, --- X ACI 318: 1913.3 •�• 1 I wl l%,ICLC is aaiiipieu to iaDncaie ASTM C 172 specimens for strength tests, perform slump and air content tests and determine the temperature of the X --- ASTM C 31 1913.10 concrete. ACI 318: 5.6, 5.8 7. ❑ Inspection of concrete and shotcrete placement for 1913.6, 1913.7, proper application techniques. X --- ACI 318: 5.9, 5.10 1913.8 8. ❑ Inspection for maintenance of specified curing temperature and techniques. --- X ACI 318: 5.11-5.13 1913.9 9. Inspection of prestressed concrete: ❑ Application of prestressing forces. X --- ACI 318:18.20 ❑ Grouting of bonded prestressing tendons in the seismic force -resisting system. X --- ACI 318: 18.18.4 -- 10. ❑ Erection of precast concrete members. --- X ACI 318: Ch. 16 -- 11. ❑ Verification of in-situ concrete strength, prior to stressing of tendons in posttensioned concrete and prior to removal of shores and forms from beams and structural slabs. --- X ACI 318: 6.2 -- 12. ❑ Inspect formwork for shape, location, and dimensions of the concrete member being formed. -'- X ACI 318: 6.6.1 --- 13. ❑ Bolts Installed in Existing Masonry or Concrete ❑ Direct tension testing of existing anchors. --- X See ICC ES Reports form special inspection requirements for proprietary products ❑ Direct tension testing of new bolts. --- X ❑ Torque testing of new bolts. ___ X ❑ Prequalification test for bolts and other types of anchors. --- X 14. ❑ Other: 011 L "ti \A V) "\ SpecialnspectionForm_2012.doc revised 09/06/12 SpecialnspectionForm_2012.doc revised 09106112 REFERENCE FOR CRITERIA VERIFICATION AND INSPECTION C P IBC TMS 402/ACI TMS 402/ACI SECTION 530/ASCE 5 530/ASCE 6 INSPECTION OF LEVEL 1 MASONRY 1. ❑ Compliance with required inspection provisions of the construction documents and the approved --- X --- --- Art. 1.5 submittals shall be verified. 2. ❑ Verification of fR, and faac prior to construction except where specifically exempted by this code. -- - X --- --- Art. 1.4B 3. ❑ Verification of slump flow and VSI as delivered to the site for self consolidating grout. X ---1. --- --- Art.1.5B.1.b.3 4. As masonry construction begins, the following shall be verified to ensure compliance: ❑ Proportions of site -prepared mortar. --- X --- --- Art. 2.6A ❑ Construction of mortar joints. --- X --- --- Art.3.36 ❑ Location of reinforcement, connectors, prestressing tendons, and anchorages. --� --- "-- ❑ Prestressing technique. --- X --- --- Art. 3.66 ❑ Grade and size of prestressing tendons and anchorages. -" X ___ __- Art. 2.4B, 2.4H 5. During construction the inspection program shall verify.- erify:❑ 0Size and location of structural elements. --- X --- --- Art. 3.3F ❑ Type, size, and location of anchors, including other details of anchorage of masonry to --- X --- Sec. 1.2.2(e), --- structural members, frames or other construction. 1.16.1 ❑ Specified size, grade, and type of reinforcement, anchor bolts, prestressing tendons and --- X --- Sec. 1.15 Art. 2.4, 3.4 anchorages. ❑ Welding of reinforcing bars. X ___ _-- ___ ❑ Preparation, construction and protection of masonry during cold weather (temperature below___ X Sec. 2104.3, 40 degrees F) or hot weather (temperature above 2104.4 ___ Art. 1.8C, 1.8D 90 degrees F). ❑ Application and measurement of prestressing X T--- force. -` --- Art. 3.613 6. Prior to grouting the following shall be verified to ensure compliance: ❑ Grout space is clean. --- X --- --- Art. 3.2D ❑ Placement of reinforcement and connectors and prestressing tendons and anchorages. --- X __- Sec. 1.3 Art. 3.4 ❑ Proportions of site -prepared grout and prestressing grout for bonded tendons. ___ X --- "" Art. 2.6B ❑ Construction of mortar joints. --- X --- --- Art. 3.313 7. Grout placement.- lacement:❑ 0Grout placement shall be verified ensure compliance. X _"' -" ___ Art. 3.5 ❑ Observe grouting of prestressing bonded tendons. X --- --- --- Art 3.6C SpecialnspectionForm_2012.doc revised 09106112 SpecialnspectionForm 2012.doc revised 09/06/12 REFERENCE FOR CRITERIA VERIFICATION AND INSPECTION C P IBC TMS 402/ACI TMS 402/ACI SECTION 530/ASCE 5 530/ASCE 6 8. ❑ Preparation of any required grout specimens, Sec. mortar specimens, and/or prisms shall be --- X 2105.2.2, --- Art. 1.4 observed. 2105.3 INSPECTION OF LEVEL 2 MASONRY 1. ❑ Compliance with required inspection provisions of the construction documents and the approved --- X --- --- Art. 1.5 submittals. 2. ❑ Verification of f m and f AAS prior to construction and for every 5,000 square feet during --- X --- --- Art. 1 AB construction. 3. ❑ Verification of proportions of materials in premixed or preblended mortar and grout as --- X --- --- Art. 1.513 delivered to the site. 4. ❑ Verification of slump flow and VSI as delivered to X ___ --- _-_ Art. 1.513.1.b.3 the site for self consolidating rout. 5. The following shall be verified to ensure compliance: ❑ Proportions of site -prepared mortar, grout, and ___ X ___ ___ Art. 2.6A prestressing grout for bonded tendons. ❑ Placement of masonry units and construction of --- X ___ ___ Art. 3.36 mortar joints. ❑ Placement of reinforcement, connectors and --- X ___ Sec. 1.15 Art. 3.4, 3.6A prestressing tendons and anchorages. ❑ Grout space prior to grouting. X --- --- --- Art. 3.2D ❑ Placement of grout. X ___ ___ _-- Art. 3.5 ❑ Placement of prestressing grout. X --- --- -- Art. 3.6C ❑ Size and location of structural elements. --- X --- --- Art. 3.3F ❑ Type, size, and location of anchors, including other details of anchorage of masonry to X ___ ___ Sec.1.2.2(e) structural members, frames and other construction. ❑ Specified size, grade, and type of reinforcement, anchor bolts, prestressing tendons and --- X --- Sec. 1.15 Art. 2.4, 3.4 anchorages. ❑ Welding of reinforcing bars. X--- ___ Sec. 2.1.9.7.2, --- 3.3.3.4 (b) ❑ Preparation, construction, and protection of masonry during cold weather (temperature below --- X Sec. 2104.3, -__ Art. 1.8C, 1.8D 40 degrees F) or hot weather (temperature above 2104.4 90 degrees F). ❑ Application and measurement of prestressing X ___ ___ --_ Art. 3.66 force. 6. ❑ Preparation of any required grout specimens, Sec. mortar specimens, and/or prisms shall be X --- 2105.2.2, --- Art. 1.4 observed. 2105.3 SpecialnspectionForm 2012.doc revised 09/06/12 REFERENCED ]IBC VERIFICATION AND INSPECTION C P STANDARD REFERENCE INSPECTION OF WOOD 1. ❑ Inspect prefabricated wood structural elements and --- --- assemblies in accordance with Section 1704.2. --- 1704.6 2. ❑ Inspect site built assemblies. --- --- 3. Inspect high -load diaphragms: ❑ Verify grade and thickness of sheathing. --- 0 Verify nominal size of framing members at adjoining --- -_- panel edges. ❑ Verify nail or staple diameter and length, --- --- --- 1704.6.1 ❑ Verify number of fastener lines, --- "' ❑ Verify spacing between fasteners in each line and at --- __- edge margins. 4. ❑ Metal -plate -connected wood trusses spanning 60 feet or greater: Verify temporary installation --- 1704.6.2 restraint/bracing and the permanent individual truss --- X member bracing are installed in accordance with the approved truss submittal package. REQUIRED VERIFICATION AND INSPECTION OF SOIL 1. ❑ Verify materials below footings are adequate to --- X achieve the desired bearing capacity. 2. ❑ Verify excavations are extended to proper depth and --- X have reached proper material. 3. ❑ Perform classification and testing of compacted fill --- X --- Table 1704.7 materials. 4. ❑ Verify use of proper materials, densities and lift thicknesses during placement and compaction of X --- compacted fill. 5. ❑ Prior to placement of compacted fill, observe subgrade --- X and verify that site has been prepared properly. REQUIRED VERIFICATION AND INSPECTION OF DEEP DRIVEN FOUNDATION ELEMENTS 1. ❑ Verify element materials, sizes and lengths comply X --- with the requirements. 2. ❑ Determine capacities of test elements and conduct X --- additional load tests, as required. 3. ❑ Observe driving operations and maintain complete X --- and accurate records for each element. 4. ❑ Verify locations of piles and their plumbness, confirm Table 1704.8 type and size of hammer, record number of blows per --- foot of penetration, determine required penetrations to X --- achieve design capacity, record tip and butt elevations and document any damage to foundation element. 5. ❑ For steel elements, perform additional inspections in --_ --- accordance with Section 1704.3. 6. ❑ For concrete elements and concrete filled elements, perform additional inspections in accordance with --- --- Section 1704.4. SpecialnspectionForm_2012.doc revised 09/06/12 BUILDING ENERGY ANALYSIS REPORT PROJECT: Addition & Remodeling to the Residence 20153 John Dr, Cupertino, CA 95014 Project Designer: 20153 JohnDr, , �M` Cupertino, CA 9501 �1 Report Prepared by: Arash Nazari, P.E. A & N Design Group 19126 Haynes St. #2 Reseda, CA 91335 818288-4361 A &� DESIGN GROUP Job Number: CO 629 Date: 8/19/2015 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 2013 Building Energy Efficiency Standards. This program developed by EnergySoft, LLC — www.energysoft.corn. TABLE OF CONTENTS I Cover Page Table of Contents Form CF -1 R -PRF -01 -E Certificate of Compliance Form RMS -1 Residential Measures Summary Form MF -1 R Mandatory Measures Summary EEnergyPro 6.7 by EnergySaft Job Number: ID: 629 User Number: 8033 2 3 12 14 CERTIFICATE OF COMPLIANCE - RESIDENTIAL PERFORMANCE COMPLIANCE METHOD CF1R-PRF-01-E Project Name: Residential Building Calculation Date/Time: 14:57, Wed, Aug 19, 2015 Page 1 of 9 Calculation Description: Title 24 Analysis Input File Name: 20153 John Dr, Cupertino, CA 95014.xm1 GENERAL INFORMATION ENERGY USE SUMMARY 01 Project Name Residential Building 04 05 02 Calculation Description Title 24 Analysis 08 Energy Use (kTDV/ft2-yr) 03 Project Location 20153 John Dr, Compliance Margin Percent Improvement 04 City Cupertino 05 Standards Version Compliance 2015 06 Zip Code 95014 07 Compliance Manager Version BEMCmpMgr 2013-4 (744) 08 Climate Zone CZ4 09 Software Version EnergyPro 6.6 10 Building Type Single Family 11 Front Orientation (deg/Cardinal) 180 12 Project Scope Addition and/or Alteration 13 Number of Dwelling Units 1 14 Total Cond. Floor Area lft� 2603 15 Number of Zones 3 16 Slab Area (ft3 0 17 Number of Stories 2 18 Addition Cond. Floor Area 581 19 Natural Gas Available Yes 20 Addition Slab Area (ft) 0 21 Glazing Percentage ('%)T12,4116 COMPLIANCE RESULTS 01 Building Complies with Computer Performance 02 This building DOES NOT require HERS Verification 03 This building incorporates one or more Special Features shown below Registration Number: Registration DateMme: HERS Provider: CA Building Energy Efficiency Standards - 2013 Residential Compliance Report Version - CF1R-07082015-744 Report Generated at: 2015-08-19 15:01:27 ENERGY USE SUMMARY 04 05 06 07 08 Energy Use (kTDV/ft2-yr) Standard Design Proposed Design Compliance Margin Percent Improvement Space Heating 48.25 46.72 1.53 3.2% Space Cooling 30.69 30.56 0.13 0.4% IAO Ventilation 0.00 0.00 0.00 0.0% Water Heating 12.23 12.23 0.00 0.0% Photovoltaic Offset ---- 0.00 0.00 ---- Compliance Energy Total 91.17 89.51 1.66 1.8% Registration Number: Registration DateMme: HERS Provider: CA Building Energy Efficiency Standards - 2013 Residential Compliance Report Version - CF1R-07082015-744 Report Generated at: 2015-08-19 15:01:27 CERTIFICATE OF COMPLIANCE - RESIDENTIAL PERFORMANCE COMPLIANCE METHOD CF1 R -PRF -01-E Project Name: Residential Building Calculation Date/Time: 14:57, Wed, Aug 19, 2015 Page 2 of 9 Calculation Description: Title 24 Analysis Input File Name: 20153 John Dr, Cupertino, CA 95014.xml REQUIRED SPECIAL FEATURES The following are features that must be installed as condition for meeting the modeled energy performance for this computer analysis. • Ducts with high level of Insulation • Cathedral Ceiling • New ductwork added Is less than 40 ft. In length I HERS FEATURE SUMMARY The following is a summary of the features that must be field -verified by a certified HERS Rater as a condition for meeting the modeled energy performance for this computer analysis. Additional detail is provided in the building components tables below. Building -level Verifications: None — Cooling System Verifications: --None -- HVAC Distribution System Verifications: -.None -- Domestic Hot Water System Veriticatlons: - None — ENERGY DESIGN RATING This is the sum of the annual TDV energy consumption for energy use components included in the performance compliance approach for the Standard Design Building (Energy Budget) and the annual TDV energy consumption for fighting and components not regulated by Title 24, Part 6 (such as domestic appliances and consumer electronics) and accounting for the annual TDV energy offset by an on-site renewable energy system. Reference Energy Use Energy Design Rating Margin Percent Improvement 17 Total Energy (kTDV1f2-yr)' 1136,46 134.80 1.66 1.2% • includes calculated Appliances and Miscellaneous Energy Use (AMEU) BUILDING - FEATURES INFORMATION 01 02 03 04 05 06 07 Project Name Conditioned Floor Area (112) Number of Dwelling Units Number of Bedrooms Number of Zones Number of Ventilation Cooling Systems Number of Water Heating Systems Residential Building 2603 1 5 3 0 1 Registration Number: Registration Date/Time: HERS Provider: CA Building Energy Efficiency Standards - 2013 Residential Compliance Report Version - CF1R-07082015-744 Report Generated at: 2015-08-19 15:01:27 CERTIFICATE OF COMPLIANCE - RESIDENTIAL PERFORMANCE COMPLIANCE METHOD CF1 R -PRF -01-E Project Name: Residential Building Calculation Date/Time: 14:57, Wed, Aug 19, 2015 Page 3 of 9 Calculation Description: Title 24 Analysis Input File Name: 20153 John Dr, Cupertino, CA 95014.xml ZONE INFORMATION 01 02 03 04 0S 06 07 Zone Name Zone Type HVAC System Name Zone Floor Area (ftp Avg. Gelling Height Water Heating System 1 Water Heating System 2 Existing Conditioned Existing AC1 1132 9 DHW Sys 1 Addition Conditioned Existing AC1 581 9 DHW Sys 1 2nd Floor Conditioned Existing AC2 890 9 DHW Sys 1 OPAQUE SURFACES 01 02 03 04 05 06 07 08 09 10 Name Zone Construction Azimuth Window &Door Orientation Gross Area (tt2j Area (ft) 'Tilt (deg) Status Verified Existing Condition N Wail Existing Default Wall Prior tol978 0 Back 503 109 90 Existing No S Wall Existing Default Wall Prior to 1978 180 Front 210 90 Existing No E Wall Existing Default Wall Prior tot 978 90 Right 408 7.5 90 Existing No W Wall Existing Default Wall Prior to 1978 270 Left 258 16 90 Existing No Roof 2 Existing Default Root Prior to 197 700 Existing No Raised Floor Existing R-19 Floor With Crawispac 1132 Altered N/A W Wall 2 Addition R-15 Wall 270 Left 150 90 New N/A S Wall 2 Addition R-15 Wall 180 Front 370 74 90 New N/A E Wall 2 Addition R-15 Wall 90 Right 80 8 90 New N/A Roof 3 Addition R-30 Roof Attic 581 New N/A Raised Floor 2 Addition R-19 Floor With Crawispac 581 New N/A N Wall 2 2nd Floor Default Wall Prior tol978 0 Back 230 32 90 Existing No S Wall 3 2nd Floor Default Wall Prior to 1978 180 Front 230 48 90 Existing No W Wall 3 2nd Floor Default Wall Prior tot 978 270 Left 388 12 90 Existing No E Wall 3 2nd Floor Default Wall Prior to 1978 90 Right 388 24 90 Existing No Roof 4 2nd Floor Default Roof Prior to 197 890 Existing No Floor over Garage2nd Floor Default Floor Crawispace 420 Existing No Registration Number: Registration Date/Time: CA Building Energy Efficiency Standards - 2013 Residential Compliance Report Version - CF1R-07082015-744 HERS Provider: Report Generated at: 2015-08-19 15:01:27 CERTIFICATE OF COMPLIANCE - RESIDENTIAL PERFORMANCE COMPLIANCE METHOD CF1 R -PRF -01 -E Project Name: Residential Building Calculation DateMme: 14:57, Wed, Aug 19, 2015 Page 4 of S Calculation Description: Title 24 Analysis Input File Name: 20153 John Dr, Cupertino, CA 95014.xmi OPAQUE SURFACES — Cathedral Ceilings 01 02 03 04 05 06 06 07 08 08 10 11 12 13 Roof Reflectance Roof Emittance Radiant Barrier Cool Root Statu a Verified Existing Condition Attic Existing Attic RoofExisting Ventilated Roof 0.1 Framin No Ver"Ied Enlgsti No Attic Addition Orientatio Area Skylight Roof Rise Roof Roof Reflectan Roof g Statu Existing Name Zone Type n (11� Area (ft2) (x in 12) Pitch Tilt(deg) ce Emittance Factor s Condition Roof Existing Default Roof Prior Back 12.1 6 0 0 0 0.1 0.85 0,1 Exigstin No to 1971 ATTIC 01 02 03 04 05 06 07 08 09 1 10 Name Construction Type Roof Rise Roof Reflectance Roof Emittance Radiant Barrier Cool Root Statu a Verified Existing Condition Attic Existing Attic RoofExisting Ventilated 0 0.1 0.85 No No Enlgsti No Attic Addition Attic RoofAdditlon Ventilated 0 0.1 0.85 Yes No New No Attic 2nd Floor Attic Roof2nd Floor Ventilated 0 0.1 0.85 No No Enigsti No Registration Number: Registration Date/rme: HERS Provider: CA Building Energy Efficiency Standards - 2013 Residential Compliance Report Version - CF1R-07082015-744 Report Generated at: 2015-08-1915:01:27 CERTIFICATE OF COMPLIANCE - RESIDENTIAL PERFORMANCE COMPLIANCE METHOD CF1R-PRF-01-E Project Name: Residential Building Calculation DateJTlme: 14:57, Wed, Aug 19, 2015 Page 5 of 9 Calculation Description: Title 24 Analysis Input File Name: 20153 John Dr, Cupertino, CA 95014.xml WINDOWS 01 02 03 04 05 06 07 08 09 10 11 Name Surface (Orlwdation-Azimuth) Width(ft) Height (ft) Multipile r Area (ftp U -factor SHGC Exterior Shading Status Verified Existing Condition Windows N Wall (Back -0) ---- -•-- 1 40.0 0.99 0.74 Insect Screen (default) Existing No Windows 2 N Wall (Back -0) ---- 1 15.8 0.99 0.74 Insect Screen (default) Existing No Windows 3 N Wall (Back -0) ---- ---- 1 53.2 0.99 0.74 Insect Screen (default) Existing No Windows 4 E Wall (Right -90) ---- ---- 1 7.5 0.99 0.74 Insect Screen (default) Existing No Windows 5 W Wall (Left -270) ---- -•-- 1 8.0 0,99 0.74 Insect Screen (default) Existing No Windows 6 W Wali (Left -270) ---- •--• 1 8.0 0.99 0.74 Insect Screen (default) Existing No Skylight Roof (Back -0) ---- 1 6.0 0.51 0.26 None New NIA Skylight 2 Roof (Back -0) ---- ---- 1 6.0 0.51 0.26 None New N/A Windows 7 S Wali 2 (Front -180) ---- ---- 1 24.0 0.29 0.21 Insect Screen (default) New NIA Windows 8 S Wail 2 (Front -180) ---- ---- 1 6.0 0.29 0.21 Insect Screen (default) New NIA Windows 9 S Wall 2 (Front -180) 1 24.0 0.29 0.21 Insect Screen (default) New N/A Windows 10 E Wall 2 (Right -90) ---- 1 8.0 0.29 0.21 Insect Screen (default) New N/A Windows 11 N Wall 2 (Back -0) ---- 1 32.0 0.99 0.74 Insect Screen (default) Existing No Windows 12 S Wall 3 (Front -180) ---- 1 24.0 0.99 0.74 Insect Screen (default) Existing No Windows 13 S Wali 3 (Front -180) ---- 1 24.0 0.99 0.74 Insect Screen (default) Existing No Windows 14 W Wall 3 (Left -270) ---- ---- 1 12.0 0.99 0.74 Insect Screen (default) Existing No Windows 15 E Wall 3 (Right -90) ---- 1 12.0 0.99 0.74 Insect Screen (default) Existing No Windows 16 E Wail 3 (Right -90) 1 12.0 0.99 1 0.74 Insect Screen (default) Existing No DOORS 01 02 03 04 05 06 Name Side of Building Area (ftp U -factor Status Verified Existing Condition Door S Wall 2 20.0 1 0.50 New No Registration Number: Registration Date/Time: HERS Provider: CA Building Energy Efficiency Standards - 2013 Residential Compliance Report Version - CFiR-07082015-744 Report Generated at: 2015-08-19 15:01:27 CERTIFICATE OF COMPLIANCE - RESIDENTIAL PERFORMANCE COMPLIANCE METHOD CF1R-PRF-01-E Project Name: Residential Building Calculation DatWnme: 14:57, Wed, Aug 19, 2015 Page 6 of 9 Calculation Description: Title 24 Analysis Input File Name: 20153 John Dr, Cupertino, CA 95014.xmi OPAQUE SURFACE CONSTRUCTIONS 01 02 03 04 05 06 07 Total Cavity Winter Design Construction Name Surface Type Construction Type Framing R -value U -value Assembly Layers Cavity / Frame: no insul. / 2x4 Top Chrd 2x4 Top Chord of Roof Truss @ 24 Roof Deck: Wood Siding/sheathing/decking Attic RoofExisting Attic Roofs Wood Framed Ceiling in. O.C. none 0.644 Roofing: Light Roof (Asphalt Shingle) Inside Finish: Gypsum Board • Cavity/ Frame: no insut / 2x4 Exterior Finish: Wood Default Wall Prior to 1978 Exterior Walls Wood Framed Wail 2x4 @ 16 in. O.C. none 0.302 Siding/sheathing/decking Inside Finish: Gypsum Board Ceilings (below Cavity/Frame: R-9.1 /2x4 Default Roof Prior to 197 attic) Wood Framed Ceiling 2x4 @ 16 in. O.C. R 11 0.083 Over Floor Joists: R-1.9 insul. inside Finish: Gypsum Board Cavity/ Frame: R-11 12X4 Roof Deck: Wood Siding/sheathing/decking Default Roof Prior to 1971 Cathedral Ceilings Wood Framed Ceiling 2x4 @ 16 in. O.C. R 11 0.088 Roofing: Light Roof (Asphalt Shingle) Floor Surface: Carpeted Floors Over Floor Deck: Wood Siding/sheathing/decking R-19 Floor With Crawispac Crawispace Wood Framed Floor 2x6 @ 16 in. O.C. R 19 0.049 Cavity/Frame: R -19/2x6 Cavity/Frame: no insul. /2x4 Top Chrd 2x4 Top Chord of Roof Truss @ 24 Root Deck: Wood Siding/sheathing/decking Attic RoofAddition Attic Roofs Wood Framed Ceiling In. O.C. none 0.644 Roofing: Light Roof (Asphalt Shingle) Inside Finish: Gypsum Board Cavity/Frame: R -15/2x4 Exterior Finish: Wood R-15 Wall Exterior Wails Wood Framed Wali 2x4 @ 16 In. O.C. R 15 0.089 Siding/sheathing/decking inside Finish: Gypsum Board Ceilings (below Cavity/Frame: R-9.1 /2x4 R-30 Roof Attic attic) Wood Framed Ceiling 2x4 @ 24 in. O.C. R 30 0.032 Over Floor Joists: R-20.9 insul. Cavity/ Frame: no Insul. / 2x4 Top Chrd 2x4 Top Chord of Roof Truss @ 24 Roof Deck: Wood Siding/sheathing/decking Attic Roof2nd Floor Attic Roofs Wood Framed Ceiling In. O.C. none 0.644 Roofing: Light Roof (Asphalt Shingle) Floor Surface: Carpeted Floors Over Floor Deck: Wood Siding/sheathing/decking Default Floor Crawlspace Crawispace Wood Framed Floor 2x12 @ 16 in. O.C. none 0.216 CavitylFrame: no insul. /2x12 Floor Surface: Carpeted Floor Deck: Wood Siding/sheathing/decking Cavity /Frame: no insul. / 2x12 Default Floor Crawlspacel Interior Floors Wood Framed Floor 2x12 @ 16 in. O.C. none 0.196 Ceiling Below Finish: Gypsum Board Registration Number: Registration Date/Time: HERS Provider: CA Building Energy Efficiency Standards - 2013 Residential Compliance Report Version - CF1R-07082015-744 Report Generated at: 2015-08-19 15:01:27 CERTIFICATE OF COMPLIANCE - RESIDENTIAL PERFORMANCE COMPLIANCE METHOD CF1 R -PRF -01-E Project Name: Residential Building Calculation Date/Tlme: 14:57, Wed, Aug 19, 2015 Page 7 of 9 Calculation Description: Title 24 Analysis Input File Name: 20153 John Dr, Cupertino, CA 95014.xmi WATER HEATING SYSTEMS 01 02 03 04 05 06 07 08 Name System Type Distribution Type Water Heater Number of Heaters Solar Fraction (%) Status Verified Existing Condition DHW Sys 1 DHW Standard DHW Heater 1 1 Annual Existing No WATER HEATERS 01 02 03 04 05 06 07 08 Name Heater Element Type Tank Type Tank Volume (gal) Energy Factor or Efficiency Input Rating Tank Exterior Insulation R -value Standby Loss (Fraction) DHW Heater 1 Natural Gas Small Storage 50 0.575 EF 40000-Btu/hr 0 0 WATER HEATING - HERS VERIFICATION 01 02 03 04 05 06 07 Name Pipe Insulation Parallel Piping Compact Distribution Point -of Use Recirculation with Manual Control Recirculation with Sensor Control DHW Sys 1 n/a n/a n/a n/a n/a n/a SPACE CONDITIONING SYSTEMS 01 02 03 04 05 06 07 08 09 CntrlFurnace - Fuel -fired central furnace 82 AFUE Heating System Cooling System 82 AFUE Distribution Fan Floor Area Verified Existing Name System Type Name Ducted Name Ducted System System Served Status Condition Existing AC1 Other Heating and Heating Yes Cooling Yes Air Distribution HVAC Fan 1713 Existing No Cooling System Component 1 Component 1 System 1 1 Existing AC2 Other Heating and Heating Yes Cooling Yes Air Distribution HVAC Fan 890 Existing No Cooling System Component 2 Component 2 System 2 2 HVAC - HEATING SYSTEMS 01 02 03 Name Type Efficiency Heating Component 1 CntrlFurnace - Fuel -fired central furnace 82 AFUE Heating Component 2 CntrlFurnace - Fuel -fired central furnace 82 AFUE Registration Number: Registration Date/Time: HERS Provider: CA Building Energy Efficiency Standards - 2013 Residential Compliance Report Version - CF1R-07082015-744 Report Generated at: 2015-08-19 15:01:27 CERTIFICATE OF COMPLIANCE - RESIDENTIAL PERFORMANCE COMPLIANCE METHOD CFIR-PRF-01-E Project Name: Residential Building Calculation Date/Tlme: 14:57, Wed, Aug 19, 2015 Page 8 of 9 Calculation Description: Title 24 Analysis Input File Name: 20153 John Dr, Cupertino, CA 95014.xmi HVAC - COOLING SYSTEMS 01 02 03 04 05 08 07 07 08 Efficiency 10 Multi -speed Name System Type EER SEER Zonally Controlled Compressor HERS Verification Cooling Component 1 SplitAirCond - Split air conditioning 9 10 No No N/A Location system Status Condition Verification Air Distribution System 1 Ducts located in attic Cooling Com nent 2 Po SplitAirCond - Split air conditioning 9 10 -7 No No N/A N/A system Ducts located in attic Existing (not specified) 8.0 Attic Attic HVAC - DISTRIBUTION SYSTEMS 01 02 03 04 05 08 07 08 09 10 Insulation Supply Duct Return Duct Verified Existing HERS Name Type Duct Leakage R -value Location Location Bypass Duct Status Condition Verification Air Distribution System 1 Ducts located in attic Existing (not specified) 8.0 Attic Attic None Existing + New No N/A Air Distribution System 2 Ducts located in attic Existing (not specified) 8.0 Attic Attic None Existing + New No N/A Wil (indoor Air Quality) FANS 01 02 03 04 05 Name WQ CFM WQ Fan Type WQ Recovery Effectiveness(%) HERS Verification SFam IAQVentRpt 0 Default 0 Not Required Registration Number: Registration Date/Time: HERS Provider: CA Building Energy Efficiency Standards - 2013 Residential Compliance Report Version - CF1R-07082015-744 Report Generated at: 2015-08-1915:01:27 CERTIFICATE OF COMPLIANCE - RESIDENTIAL PERFORMANCE COMPLIANCE METHOD CFI R -PRF -01-E Project Name: Residential Building Calculation DateMme: 14:57, Wed, Aug 19, 2015 Page 9 of 9 Calculation Description: Title 24 Analysis Input File Name: 20153 John Dr, Cupertino, CA 95014.xmi DOCUMENTATION AUTHOR'S DECLARATION STATEMENT 1. 1 certify that this Certificate of Compliance documentation is accurate and complete. Documentation Author Name: Documentation Author Signature: Arash Nazari, P.E. Company: Signature Date: A & N Design Group 8/19/2015 Address: 19126 Haynes St. #2 CEA/HERS Certification Identif cation (if applicable): Cityrstat Reseda, CA 91335 Phone:818-288-4361 RESPONSIBLE PERSON'S DECLARATION STATEMENT I certify the following under penalty of perjury, under the laws of the State of California: 1. I am eligible under Division 3 of the Business and Professions Code to accept responsibility for the building design identified on this Certificate of Compliance. 2. 1 certify that the energy features and performance specifications identified on this Certificate of Compliance conform to the requirements of Title 24, Part 1 and Part 6 of the California Code of Regulations. 3. 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 agency for approval with this building permit application. Responsible Designer Name: Responslble Dgj;i ek "gna - i il� Maria Mokrzycki Company: Date Signed: Address: License: 20153 John Dr, City/Sfate[Zip: Phone: Cupertino, CA 95014 iC)� 3 -C)1/✓ Registration Number: Registration Date/Time: HERS Provider: CA Building Energy Efficiency Standards - 2013 Residential Compliance Report Version - CF1R-07082015-744 Report Generated at: 2015-08-1915:01:27 RESIDENTIAL MEASURES SUMMARY RMS-1 Project Name Addition & Remodeling to the Residence Building Type m Single Family ❑ Addition Alone ❑ Multi Family 12 Existing+ Addition/Afteration Date 8/19/2015 Project Address 20153 John Dr, Cupertino California Energy Climate Zone CA Climate Zone 04 Total Cond. Floor Area 2,603 Addition 581 of Units 1 INSULATION Construction Type Area Cavi Special Features Status Wall Wood Framed - no insulation 2,367 Existing Roof Wood Framed Attic R11 1,590 Existing Floor Wood Framed wrCrawl Space R 19 1,132 Altered Wall Wood Framed R 15 518 New Door Opaque Door - no insulation 20 New Roof Wood Framed Attic R 30 581 New Floor Wood Framed w/Crawf Space R 19 581 New Demising Wood Framed R 13 440 New FENESTRATION I Total Area: 323 Glazing Percerrta e: 12.4 New/Altered Avera U-Factor. 0.33 Orientation Area U-Fac SHGC Overhang Sidefins Exterior Shades Status Rear (N) 141.0 0.990 0.74 none none Bug Screen Existing Right (E) 31.5 0.990 0.74 none none Bug Screen Existing Skylight 6.0 0.510 0.26 none none None New Skylight 6.0 0.510 0.26 none none None New Left (149 28.0 0.990 0.74 none none Bug Screen Existing Front (S) 54.0 0.290 0.21 none none Bug Screen New Right (E) 8.0 0.290 0.21 none none Bug Screen New Front (S) 48.0 0.990 0.74 none none Bug Screen Existing HVAC SYSTEMS Qty. Heating Min. Eff Cooling Min. Eff Thermostat Status 1 Central Furnace 82% AFUE Split Air Conditioner 10.0 SEER Setback Existing 1 Central Furnace 82% AFUE Spilt Air Conditioner 10.0 SEER Setback Existing HVAC DISTRIBUTION Location Heating Duct Cooling Duct Location R-Value Status Existing AC Ducted Ducted Attic 8.0 Altered Existing AC Ducted Ducted Attic 8.0 Altered WATER HEATING Oty. Type Gallons Min. Eff Distribution Status EnergyPro 6.7 by En Soft User Number: 8033 RunCode: 2015.08-19715:09:24 ID: 629 Paqe 12 of 17 RESIDENTIAL MEASURES SUMMARY RMS-1 Project Name Addition & Remodeling to the Residence Building Type Ga Single Family 0 Addition Alone O Multi Family ® Existing+ Addition/Alteration Date 8/19/2015 Project Address 20153 John Dr, Cupertino California Energy Climate Zone CA Climate Zone 04 Total Cond_ Floor Area 2,603 Addition 581 of Units 1 INSULATION Construction Type Area Cavi Special Features Status Floor Wood Framed w/Crawl Space - no insulation 420 Existing Demising Wood Framed w/Crawl Space - no insulation 470 New FENESTRATION I Total Area: 323 Glazing Percentage: 12.4 % New/Altered Avera U-Factor. 0.33 Orientation Area U-Fac SHGC Overhang Sidefins Exterior Shades Status HVAC SYSTEMS Heating Min. Eff Cooling Min. Eff Thermostat Status HVAC DISTRIBUTION Location Heating Duct Cooling Duct Location R-Value Status WATER HEATING v Type Gallons Min. Eff Distribution Status En Pro 6.7 by En Soft User Number 8033 RunCode: 2015-08-19115:09:24 ID: 629 Pae 13 of 17 2013 Low -Rise Residential Mandatory Measures Summary NOTE: Low-rise residential buildings subject to the Standards must comply with all applicable mandatory measures listed, regardless of the comDliance aDDroach used. Errentionv may apply_ Review t& rvcrwrtivv rnile vertinn fur mnry infer ntinn Building Envelope Measures: §I 10.6(a)1: Doors and windows between conditioned and unconditioned spaces are manufactured to limit air leakage. § 110.6(a)5: Fenestration products (except field -fabricated windows) have a label listing the certified U -Factor, certified Solar Heat Cain Coefficient SHGC and infiltration that meets the requirements of §10-111(4). § 110.7: Exterior doors and windows are weatherstripped; all joints and penetrations are caulked and sealed. § 110.8(a): Insulation specified or installed meets Standards for Insulating Material. Indicate type and include on the CF2R. § 110 8(i): The thermal emittance and aged solar reflectance values of the cool roofing material meets the requirements of § 110.8(i) when the installation of a cool roof is specified on the CFIR. § 110.86): A radiant barrier shall have an emittance of 0.05 or less when the installation of a radiant barrier is specified on the CFI R. Minimum R-30 insulation in wood -frame ceiling; or the weighted average U -factor shall not exceed 0.03 1. Minimum R-19 in a § 150.0(a): rafter roof alteration. Attic access doors shall have permanently attached insulation using adhesive or mechanical fasteners. The attic access shall be gasketed to prevent air leakage. § 150.0(b): Loose fill insulation shall conform with manufacturer's installed design labeled R -value. § 150.0(c): Minimum R-13 insulation in 2x4 inch wood framing wall or have a U -factor of 0.102 or less (R-19 in 2x6 or 0.074 maximum U - factor). § 150.0(d): Minimum R-19 insulation in raised wood -frame floor or 0.037 maximum U -factor. §I50.0(g)1: In Climate Zones 14 and 16 a Class Il vapor retarder shall be installed on the conditioned space side of all insulation in all exterior walls, vented attics and unvented attics with air -permeable insulation. In Climate Zones 1-16 with unvented crawl spaces the earth floor of the crawl space shall be covered with a Class I or Class II § 150.0(g)2: vapor retarder. In a building having a controlled ventilation crawl space, a Class I or Class CI vapor retarder shall be placed over the earth floor of § 150.0(g)3: the crawl space to reduce moisture entry and protect insulation from condensation, as specified in the exception to Section 150.0(d). §150.0(1): Slab edge insulation shall: have a water absorption rate, for the insulation material alone without facings, no greater than 0.3"/0; have water vapor permeance rate is no greater than 2.0 perm/inch, be protected from physical damage and UV light deterioration; and when installed as part of a heated slab floor meets the requirements of § 1 I0. 150. § a�' Fenestration, including skylights, separating conditioned space from unconditioned space or outdoors shall have a maximum U- factor of 0.58; or the weighted average U -factor of all fenestration shall not exceed 0.58. Fireplaces, Decorative Gas Appliances and Gas Log Measures: §150.0(e)IA: Masonry or factory -built fireplaces have a closable metal or glass door covering the entire opening of the firebox. §I50.0(e)IB: Masonry or factory -built fireplaces have a combustion outside air intake, which is at least six square inches in area and is equipped with a readily accessible operable, and tight -fitting damper or a combustion -air control device. § 150.((e) I C: Masonry or factory -built fireplaces have a flue damper with a readily accessible control. §150.0(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, Rater Heating and Plumbing System Measures: §110.0-§110.3: HVAC equipment, water heaters, showerheads, faucets and all other regulated appliances are certified to the Energy Commission. §I 10.3(c)5: Water heating recirculation loops serving multiple dwelling units meet the air release valve, backtlow prevention, pump isolation valve, and recirculation loop connection requirements of § 110.3(c)5. Continuously burning pilot lights are prohibited for natural gas: fan -type central furnaces, household cooking appliances (appli- §110.5: ances without an electrical supply voltage connection with pilot lights that consume less than 150 Btu/hr are exempt), and pool and spa heaters. § 150.0(h)1: Heating and/or cooling loads are calculated in accordance with ASHRAE, SMACNA or ACCA using design conditions specified in 150. h)2. § 150.0(h)3A: Installed air conditioner and heat pump outdoor condensing units shall have a clearance of at least five feet from the outlet of any dryer vent § 150.0(i): Heating systems are equipped with thermostats that meet the setback requirements of § 110.2(c). § 150.0(j)IA: Storage gas water heaters with an energy factor equal to or less than the federal minimum standards shall be externally wrapped with insulation having an installed thermal resistance of R-12 or greater. § 150.00)1B: Unfired hot water tanks, such as storage tanks and backup storage tanks for solar water -heating systems, have R-12 external insulation or R-16 internal insulation where the internal insulation R -value is indicated on the exterior of the tank. For domestic hot water system piping, whether buried or unburied: the first 5 feet of hot and cold water pipes from the storage tank, all piping with a nominal diameter of 3/4 inch or larger, all piping associated with a domestic hot water recirculation system § 150.06)2A: regardless of the pipe diameter, piping from the heating source to storage tank or between tanks, piping buried below grade, and all hot water pipes from the heating source to kitchen fixtures must be insulated according to the requirements of TABLE 120.3- A. §150.06)2B: All domestic hot water pipes that are buried below grade must be installed in a water proof and non -crushable casing or sleeve that allows for installation, removal, and replacement of the enclosed pipe and insulation. 2013 Low -Rise Residential Mandatory Measures Summary § I50.00)2C: Pipe for cooling system lines shall be insulated as specified in § I50.0(j)2A. Piping insulation for steam and hydronic heating systems or hot water systems with pressure > 15 psig shall meet the requirements in TABLE 120.3-A. §150.06)3: Insulation is protected from damage, including that due to sunlight, moisture, equipment maintenance, and wind. Insulation exposed to weather shall either be rated for outdoor use or installed with a cover suitable for outdoor service. For §150.00)3A: example, protected by aluminum, sheet metal, painted canvas, or plastic cover. Cellular foam insulation protected as specified or aimed with coating that is water retardant and provides shielding from solar radiation that degrades the material. Insulation covering chilled water piping and refrigerant suction piping located outside the conditioned space shall have a Class I § l 50.0(j)3B: or Class H vapor retarding facing, or the insulation shall be installed at the thickness that qualifies as a Class I or Class II vapor retarder. Systems using gas or propane water heaters to serve individual dwelling units shall include: a 120V electrical receptacle within 3 fed of the water heater; a Category III or IV vent, or a Type B vent with straight pipe between the outside termination and the § 150.0(n)1: space where the water heater is installed; a condensate drain that is no more than 2 inches higher than the base of the installed water heater, and allows natural draining without pump assistance; and a gas supply line with a capacity of at least 200,000 Btu/hr. § 150.0(n)2: Recirculating loops serving multiple dwelling units shall meet the requirements of § 110.3(c)5. § I50.0(n)3: Solar water -heating systems and collectors shall be certified and rated by the Solar Rating and Certification Corporation (SRCC) or by a testing enc roved by the Executive Director. Ducts and Fans Measures: All air -distribution system ducts and plenums installed are sealed and insulated to meet the requirements of CMC §601.0, §602.0, §603.0, §604.0, §605.0 and ANSUSMACNA-006-2006 HVAC Duct Construction Standards Metal and Flexible 3rd Edition. Supply -air and return -air ducts and plenums are insulated to a minimum installed level of R-6.0 (or higher if required by CMC §605.0) or enclosed entirely in directly conditioned space as confirmed through field verification and diagnostic testing (RA3.1.4.3.8). Connections of metal ducts and inner core of flexible ducts are mechanically fastened. Openings shall be sealed § I50.0(m)1: 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 openings greater than '/. inch, the combination of mastic and either mesh or tape shall be used. 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. Factory -Fabricated Duct Systems shall comply with specified requirements for duct construction, connections, and closures; joints § 150.0(m)2: 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. §150.0(m)3-6: Field -Fabricated Duct Systems shall comply with requirements for: pressure -sensitive tapes, mastics, sealants, and other requirements specified for duct construction; duct insulation R -value ratings; duct insulation thickness; and duct labeling. § 150.0(m)7: All fan systems that exchange air between the conditioned space and the outside of the building must have backdraft or automatic dampers. §150.0(m)8: Gravity ventilating systems serving conditioned space have either automatic or readily accessible, manually operated dampers except combustion inlet and outlet air openings and elevator shaft vents. Insulation shall be protected from damage, including that due to sunlight, moisture, equipment maintenance, and wind but not § 150.0(m)9: limited to the following: insulation exposed to weather shall be suitable for outdoor service. For example, protected by aluminum, sheet metal, painted canvas, or plastic cover. Cellular foam insulation shall be protected as above or painted with a coating that is water retardant and provides shielding from solar radiation. §150.0(m)10: Flexible ducts cannot have porous inner cores. When space conditioning systems use forced air duct systems to supply conditioned air to an oceupiable space, the ducts shall be § 150.0(m)11: sealed and duct leakage tested, as confirmed through field verification and diagnostic testing, in accordance with Reference Residential Appendix RA3. Mechanical systems that supply air to an occupiable space through ductwork exceeding 10 feet in length and through a thermal § 150.0(m)12: conditioning component, except evaporative coolers, shall be provided with air filter devices that meet the requirements of §150.0(m)12. Space conditioning systems that utilize forced air ducts to supply cooling to an occupiable space shall have a hole for the placement of a static pressure probe (IISPP), or a permanently installed static pressure probe (PSPP) in the supply plenum. The § 150.0(m)13: space conditioning system must also demonstrate airflow > 350 CFM per ton of nominal cooling capacity through the return grilles, and an air -handling unit fan efficacy <_ 0.58 W/CFM as confirmed by field verification and diagnostic testing, in accordance with Reference Residential Appendix RA3. Zonally controlled central forced air cooling systems shall be capable of simultaneously delivering, in every zonal control mode, §150.0(m)15: an airflow from the dwelling, through the air handler fan and delivered to the dwelling, of >_ 350 CFM per ton of nominal cooling capacity, and operating at an air -handling unit fan efficacy of < 0.58 W/CFM as confirmed by field verification and diagnostic testing, in accordance with Reference Residential Appendix RA3. All dwelling units shall meet the requirements of ASHRAE Standard 62.2. Neither window operation nor continuous operation of § 150.0(0): central forced air system air handlers used in central fan integrated ventilation systems are permissible methods of providing the Whole Building Ventilation. §150.0(o)IA: Whole Building Ventilation airflow shall be confirmed through field verification and diagnostic testing, in accordance with Reference Residentialdix RA3. Pool and Spa Heating Systems and Equipment Measures: Any pool or spa heating system shall be certified to have: a thermal efficiency that complies with the Appliance Efficiency § 110.4(a): Regulations; an on-off switch mounted outside of the heater that allows shutting off the heater without adjusting the thermostat setting; a permanent weatherproof plate or card with operating instructions; and shall not use electric resistance heating. 2013 Low -Rise Residential Mandatory Measures Summary § 110.4(b)1: Any pool or spa heating equipment shall be installed with at least 36 inches of pipe between filter and heater or dedicated suction and return lines,or built connections for future solar heating. § 110.4(b)2: Outdoor pools or spas that have a heat pump or gas heater shall have a cover. § 110.4(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 pro - ed to run only during off-peak electric demand periods. § 110.5: Natural gas pool and spa beaters shall not have a continuous burning pilot light. §150.0(p): Residential pool systems or equipment shall meet specified pump sizing, flow rate, piping, filters, and valve requirements. Lighting Measures: § 110.9: All fighting control devices and systems, ballasts, and luminaires shall meet the applicable requirements of § 110.9. §150.0(k)IA: Installed luminaires shall be classified as high -efficacy or low -efficacy for compliance with §150.0(k) in accordance with TABLE 150.0-A or TABLE 150.0-8 as applicable. § 150.0(k)1B: When a high efficacy and low efficacy lighting system are combined in a single luminaire, each system shall separately comply with the applicable provisions of § 150.0(k). The wattage and classification of permanently installed luminaires in residential kitchens shall be determined in accordance: with §150.0(k)IC: §I30.0(c). In residential kitchens, the wattage of electrical boxes finished with a blank cover or where no electrical equipment has been installed, and where the electrical box can be used for a luminaire or a surface mounted ceiling fan, shall be calculated as 180 watts of low efficacy lighting electrical box. § 150.0(k)1D: Ballasts for fluorescent lamps rated 13 watts or greater shall be electronic and shall have an output frequency no less than 20 kHz. Permanently installed night lights and night lights integral to installed luminaires or exhaust fans shall be rated to consume no § 150.0(k)IE: more than 5 watts of power per luminaire or exhaust fan as determined in accordance with § 130.0(c). Night lights do not need to be controlled by vacancy sensors. §150.0(k)1F: Lighting integral to exhaust fans (except when installed by the manufacturer in kitchen exhaust hoods) shall meet the applicable requirements of § 150. § 150.0(k)2A: High efficacy Luminaires must be switched separately from low efficacy luminaires. § 150.0(k)2B: Exhaust fans shall be switched separately from lighting systems. § 150.0(k)2C: Luminaires shall be switched with readily accessible controls that permit the luminaires to be manually switched ON and OFF. §I50.0(k)2D: Controls and equipment are installed in accordance with manufacturer's instructions. § 150.0(k)2E: No control shall bypass a dimmer or vacancy sensor function if the control is installed to comply with § 150.0(k). § 150.0(k)2F: Lighting controls comply with applicable requirements of § 110.9. An Energy Management Control System (FMCS) may be used to comply with dimmer requirements if it fimctions as a dimmer § 150.0(k)2G: according to § 110.9; meets Installation Certificate requirements of § 130.4; the EMCS requirements of § 130.5; and all other requirements in §150.0(k)2. An Energy Management Control System (FMCS) may be used to comply with vacancy sensor requirements of § 150.0(k) if: it § 150.0(k)2H: functions as a vacancy sensor according to § 110.9; meefs Installation Certificate requirements of § 130.4; the EMCS requirements of § 130.5; and all other requirements in § 150.0(k)2. § 150.0(k)2I: A multiscene programmable controller may be used to comply with dimmer requirements of this section if it provides the functionality of a dimmer according to 110.9 and complies with all other applicable requirements in §150.0(k)2. § 150.0(k)3A: A minimum of 50 percent of the total rated wattage of permanently installed lighting in kitchens shall be high efficacy. Kitchen lighting includes all permanently installed lighting in the kitchen except internal lighting in cabinets that illuminate only § 150.0(k)3B: the inside of the cabinets. Lighting in areas adjacent to the kitchen, including but not limited to dining and nook areas, are considered kitchen lighting if they are not separately switched from kitchen lighting. § 150.0(k)4: Permanently installed lighting that is internal to cabinets shall use no more than 20 watts of power per linear foot of illuminated cabinet § 150.0(k)5: A minimum of one high efficacy luminaire shall be installed in each bathroom; and all other lighting installed in each bathroom shall be high efficacy or controlled by vacancy sensors. § I50.0(k)6: Lighting installed in attached and detached garages, laundry rooms, and utility rooms shall be high efficacy luminaires and controlled by vacancy sensors. § I50.0(k)7: Lighting installed in rooms or areas other than in kitchens, bathrooms, garages, laundry rooms, and utility rooms shall be high efficacy,or shall be controlled by either dimmers or vacancy sensors. Luminaires recessed into ceilings shall: be listed for zero clearance insulation contact (IC) by Underwriters Laboratories or other nationally recognized testing/rating laboratory; have a label that certifies that the luminaire is airtight with air leakage less than 2.0 CFM at 75 Pascals when tested in accordance with ASTM E283; be sealed with a gasket or caulk between the luminaire housing § 150.0(k)S: and ceiling, and shall have all air leak paths between conditioned and unconditioned spaces sealed with a gasket or caulk; and allow ballast maintenance and replacement without requiring cutting holes in the ceiling. For recessed compact fluorescent luminaries with ballasts to qualify as high efficacy for compliance with §150.0(k), the ballasts shall be certified to the Energy Commission to comply with the applicable requirements in § 110.9. For single-family residential buildings, outdoor lighting permanently mounted to a residential building or other buildings on the same lot shall be high efficacy, or may be low efficacy if it meets all of the following requirements: i. Controlled by a manual ON and OFF switch that does not override to ON the automatic actions of Items ii or iii below; and § 150.0(k)9A: ii. Controlled by a motion sensor not having an override or bypass switch that disables the motion sensor, or controlled by a motion sensor having a temporary override switch which temporarily bypasses the motion sensing function and automatically reactivates the motion sensor within 6 hours; and iii. Controlled by one of the following methods: 2013 Low -Rise Residential Mandatory Measures Summary a. Photocontrol not having an override or bypass switch that disables the photocontrol; or b. Astronomical time clock not having an override or bypass switch that disables the astronomical time clock, and which is programmed to automatically tum the outdoor lighting OFF during daylight hours; or c. Energy management control system which meets all of the following requirements: At a minimum provides the functionality of an astronomical time clock in accordance with § 110.9; meets the Installation Certification requirements in §130.4; meets the requirements for an EMCS in §130.5; does not have an override or bypass switch that allows the luminaire to be always ON; and, is programmed to automatically tum the outdoor lighting OFF during daylight hours. For low-rise multifamily residential buildings, outdoor lighting for private patios, entrances, balconies, and porches; and outdoor lighting for residential parking lots and residential carports with less than eight vehicles per site shall comply with one of the § 150.0(k)9B: following requirements: i. Shall comply with § 150.0(k)9A; or ii. Shall comply with the applicable requirements in 110.9, § 130.0, 130.2, 130.4, § 140.7 and 141.0. § 150.0(k)9C: For low-rise residential buildings with four or more dwelling units, outdoor lighting not regulated by § 150.0(k)9B or 150.0(k)9D shall comply with the Mplicable requirements in § 110.9, § 130.0, § 130.2, § 130.4 § 140.7 and § 141.0. § I50.0(k)9D: Outdoor lighting for residential parking lots and residential carports with a total of eight or more vehicles per site shall comply with the applicable requirements in 110.9 130.0 130.2 § 130.4 § 140.7 and § 141.0. §150,0(k)10- Intemaily illuminated address signs shall comply with § 140.8; or shall consume no more than 5 watts of power as determined according to §130.9(c). §150.0(k)ll: Lighting for residential parking garages for eight or more vehicles shall comply with the applicable requirements for nonresidential garages in § 110.9, § 130.0, § 130. 1, § 130.4, § 140.6 and § 141.0. In a low-rise multifamily residential building where the total interior common area in a single building equals 20 percent or less of § 150.0(k) 12-A: the floor area, permanently installed lighting for the interior common areas in that building shall be high efficacy luminaires or controlled by an occupant sensor. In a low-rise multifamily residential building where the total interior common area in a single building equals more than 20 percent of the floor area, permanently installed lighting in that building shall: § 150.0(k)12B: i. Comply with the applicable requirements in § 110.9, § 130.0, § 130. 1, § 140.6 and § 141.0; and ii. Lighting installed in corridors and stairwells shall be controlled by occupant sensors that reduce the lighting power in each space by at least 50 percent. The occupant sensors shall be capable of turning the light fully On and Off from all designed paths of ingress and egress. Solar Ready Baildings: Single family residences located in subdivisions with ten or more single family residences and where the application for a §110.10(a)l: tentative subdivision map for the residences has been deemed complete, by the enforcement agency, on or after January 1, 2014, shall comply with therequirements of 110.1 throw 110.10(e). §110.10(a)2: Low-rise multi -family buildings shall comply with the requirements of § 110.10(b) throw §110. 10(d). The solar zone shall have a minimum total area as described below. The solar zone shall comply with access, pathway, smoke ventilation, and spacing requirements as specified in Title 24, Part 9 or other Parts of Title 24 or in any requirements adopted by a local jurisdiction. The solar zone total area shall he comprised of areas that have no dimension less than 5 feet and are no less than 80 square feet each for buildings with roof areas less than or equal to 10,000 square feet or no less than 160 square feet each for §1 10.10(b)l: buildings with roof areas greater than 10,000 square feet. For single family residences the solar zone shall be located on the roof or overhang of the building and have a total area no less than 250 square feet For low-rise multi -family buildings the solar zone shall be located on the roof or overhang of the building or on the roof or overhang of another structure located within 250 feet of the building or on covered parking installed with the building project and have a total area no less than 15 percent of the total roof area of the building excluding any sky -light area. § 110.10(b)2: All sections of the solar zone located on steep -sloped roofs shall be oriented between 110 degrees and 270 degrees of true north. § 110.10(b).3A: No obstructions, including but not limited to, vents, chimneys, architectural features, and roof mounted equipment, shall be located in the solar zone. Any obstruction, located on the roof or any other part of the building that projects above a solar zone shall be located at least twice § 110.10(b)3B: the distance, measured in the horizontal plane, of the height difference between the highest point of the obstruction and the _ horizontal projection of the nearest point of the solar zone, measured in the vertical plane. § 110.10(b)4: For areas of the roof designated as solar zone, the structural design loads for roof dead load and roof live load shall be clearly indicated on the construction documents. The construction documents shall indicate: a location for inverters and metering equipment and a pathway for routing of conduit § 110.10(c): from the solar zone to the point of interconnection with the electrical service (for single family residences the point of interconnection will be the main service panel); a pathway for routing of plumbing from the solar zone to the water -heating system. § 110.10(d): A copy of the construction documents or a comparable document indicating the information from § 110.10(b) through § 110.10(c) shall be provided to the occupant. §1 10.10(e)l: The main electrical service panel shall have a minimum bulbar rating of 200 amps. The main electrical service panel shall have a reserved space to allow for the installation of a double pole circuit breaker for a § 110.10(e)2: future solar electric installation. The reserved space shall be: positioned at the opposite (load) end from the input feeder location or main circuit location, and permanently marked as "For Future Solar Electric'.