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B-2016-1677CITY OF CUPERTINO BUILDING PERMIT . BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2016-1677 21103 TAMARIND CT CUPERTINO, CA 95014-1638 (326 08 016) JONATHAN WEI CHIH I . OWNER'S NAME: PANDEYANAND KAND POONAM OWNER'S PHONE: 408-406-2196 LICENSED CONTRACTOR'S DECLARATION License Class _Q Lic. #681633 Contractor JONATHAN WEI CHIH SU Date 12/31/2017 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: 1. 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. i 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 ;d 7 permit is issued. I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Moat[' ipal Code, Section 9.18. Date 02-16-2017 I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 1. I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) 2. I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Scc.7044, Business & Professions Code). hereby affirm under penalty of perjury one of the following three declarations: 1. 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. 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 permit is issued. 3. I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If, after making this certificate of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Date 02-16-2017 SU CUPERTINO, CA 95014 ISSUED: 07/22/2016 NO: (408) 255-8999 PERMIT INFO: X BLDG —ELECT X PLUMB _ MECH X RESIDENTIAL _ COMIERCLAL JOB DESCRIPTION: CONSTRUCT (1) 2 STORY SFD (3,896 S.F.) WITH ATTACHED GARAGE (480 S.F.), COVERED PORCHES/BALCONY (620 S.F.) REV #1 (9/22/16) - REMOVE CULTURED STONE AT FRONT OF BUILDING, CHANGE WINDOWS, MODIFY DRIVEWAY, REMOVE BASE OF COLUMN AT THE PORCH ENTRY, CHANGE CRAWL SPACE SIZE TO 24" DEEP W/3" CONCRETE ISSUED 9/26/16 REV #2 - 2ND FLOOR - ADD WASHER AND DRYER; ADD 2 TANKLESS WATER HEATER; REVISE POWDER ROOM AND MEDIA Sq. Ft Floor Area: 4376 1 Valuation: $720000.00- APN Number: Occupancy Type: 326 08 016 R-3 (Custom),R-3 (Custom),U (Private Gar / Ag Bldg),U (Private Gar / Ag Bldg) PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by: Abby Ayende Date: 07/22/2016 RE -ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. Signature ofApplicant: Date: 02-16-2017 1i A ll HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 2550 5533, and 25534. Owner or authorized agent: Date: 02-16-2017 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Address ARCHITECT'S DECLARATION I understand my plans shall be used as public records. BERM CUPERT INO F7 vFQJ r nx zTR T it P0C 'V�� . — '2- 01.6 — 1,6 4 T CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMiENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE, CUPERTINO, CA 95014-3255 (408) 777-3228 -FAX (408) 777-3333 • build! no( a�cuoertino.org T INTO F7 I AT'ITITTTn kT F7 AT TT_D A—M, 11T /TT F71 nct:TCT-11 :nrrrnn r -n PROJECT ADDRESS � 0-3 T A M 14 � �� � � 1 � � 8 �%j(� I .4PP � = `:3 61 D — � O W EP,' h- P� 7 ),qjo 'Pot d `l � I PHO?' 4- ®9' 1- 19-e 2.I q/ I E-?1L� IL Y- J�"g6 Cp�j`�e`1lYl,{��� f3 .may lal}'6� q j. r p�� C % CITY, STATE, ZIP � � 6�l® rJ ��+ j4-- s�% I r X I. co S?BEET?DDPESS 1 1 ®yryry1� a`�� C CO `TACT N.A hai 7 c PHO` /� 0 `r 0 d `—'y� 1 STREE? ADDRESS 9,, e O3 T `qM k'P'j n0 C -T CITY: ST.0.T=�t�P FAX 0 Id.'r u ON?.'ER ❑ OV,^_m-BL�P_DER ❑ mv.\7ERAG;TT ❑ C0117RACTOR ❑ COR'TRSCTORAGENT ❑ ARCHITECT ❑ ENG-r\mm ❑ DE\BLOPER ❑ CONTRACTORNA?`4E LICENSENU aBERI LICENSE TI PE r\GV'1t �(�� BUS �( CONP.y1Y? At j T , �-i a c E-AAAIL �-1 S'�r I .1 �' ���' �r U� ,� FAQ ' STREET kDDRESSSTATE, ZIP. ARCHITECTIENGINEERN.AA4E LIC�SE U_1BER 3i�S. LIC I �l Aj CA(?I COMPA_\YNAh4E E -?1 ML e FAX STREET ADDRESS i CITY, STATE, ZIP I PHONE DESCRIPTION OF \\'ORl: cK� \Ji% C1� .' k4? /A � � L,6 �'6 � � r� � 1 �' %J�j G d� �U 2 to•�nv- tC'SS i �k [ e S� �' uC�C'C '°t'�r r EXISTL\'G USE PROPOSED USF CONSUL TI'PE _ STORIES USE TYPE OCC. I SQ.FT. VALUATION' (S) EXISTG ;NE'VVFLOOR DE3,40 TOTAL AREA AREA AREA KET AREA - BATHROOM, KITCHEN OTHER RE,40DELAREA RIniODELAREA REMODEL AREA PORCHARE.A DECKP.REA TOT.ALDECIC-PORCH,�,REA GARAGEfiRE0.: [J DETACH ❑ ATTACH I D %\ TLLM LNITS: IS A SECOND LTIT ❑ YES SECOND STORY EI -YES bELNG ADDED? ❑ NO ADDITION? ❑ NO 1 PRE-4,°?LICATIO_. T=5 IF YES.PROVIDE COPY OF ❑❑ AM APPL = ❑ NO PL4\'\ 'G APPROVU PL_\'.1 AL LUTEA I SLD '� ITS 5 THE G .4 EICHLER BOASE? ❑ NO - - - 1 - FE _.. IZ ED yY:=: 1` '" =iZt>_ z:::':=i TOTALVALUATION: ALL_ATIO\: - - By my signature below, I certff�, to each of the follow ing: I am the property owner or authorized agent tlo act on the property owner's behalf. I have read this application and the information I have provided is correct. I ha e ead the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to buil c6on. I ho • e epresentatives of Cupertino to enter the above *d-nt ned`property for inspection proposes. LL f Si gDature of Applicant/Agent: Date: 1 �� SUPPLEI\�iEI�T.4L I�FORA7-�TIO?\t RE UIRED Q PL4 i:CHECKTYPEi;;°; -' ROU'TING SLIP .:- ..., . �::;:=-:>:::❑:::..:,r BLJLDI'�G PLAN RE\ZE\i: 7\e\v SFD or Mut Ifalnlly d\a ellmgs. app.} fordemolition p m7rt for existing buTlding(s). Demolition pennit Is required prior to Issuance of building permit Tor new building. 0I .E1PREss „ ; ::<•.:: .: . :.::::.:.:::;::: ":;�.:PL�T�\II GPL �N PE\'IE}V . `-;= '-'>=." Commercial Bldgs: Provide a completed hazardous -Materials Disclosure lorinuam Hazardous '_t1pten a1s are t,ma as.d as part oT t,ia prG .ct. —, .:;:r:•:::;;; :: r - - F prior toCo v of PlanninQ n ro\a1 Letter or \ e6tin with Planning SANT ARl SE\\ERI)ISTRICT submittal of Building Permit application.= :?oR , ,_,- ::.,.:_s_.. ,,:. . ........... °.E;\l`IRO'�?1iE:1`TAi;HEALTII=_ :.;...;.::::�.:r=:.•;;:.>_-,.�;-�:,:;I:-:...::.. ,-....,.. .:?'�=s B7do1pp_2011.do6 revised 06121/11 CUPERTINO SANITARY DISTRICT 20863 Stevens Creek Blvd #100, Cupertino, CA 95014 Tel (408) 253-7071 • Fax (408) 253-5173 �a,;..ri SRNirAgy CUPERTINO SANITARY DISTRICT PERMIT I Cupertino Sanitary District. has adopted Resolution No. 1263, Building Permit Request (Over -the -Counter) ingle Family Project ❑ Multi -Family Project ❑ Commercial Project Project Address:- 11 03S. C_ T, C U& P T> i\l V fi C 14 - Permit Number: (f? '%o t ("r — Scope of Work: L a.VLA 8Xy fX1,Ai � 7 ; a V C-YIC4 > n A�acde_a )a S� q Owner/Applicant Name: _6 INP )%j ,'P 12.(+(457 Phone: +V'? 4-01 2'1_W _S"i Address: Date: EU (-+ Prepared By: Authorized Representative I, as property owner or authorized agent, acknowledge that all Cupertino Sanitary District requirements will be met and all required fees will be paid prior tothe approval of fins inspection for proposed project. Date: Signature:�- Owner / Auth ized Agent CUPERTINO SANITARY DISTRICT OFFICE USE ONLY Pre -inspection Required Date Scheduled: F-] Final Inspection Required Date: Conditional Approval By: Authorized Representative Cupertino Sanitary District District will notify owner of the required fee within 5 days after Pre -Inspection has been completed and cc City of Cupertino. ❑ Inspection Fee Paid Date Paid: Inspection Fees: O $250/unit - Single Family Residential already connected, but new cleanout is required (� $150/unit - Single Family Residential already connected with existing cleanout: in working order $350 Minimum — Commercial and Retail Actual Amount: $200/each — Disconnect and/or abandon lateral service Connection Permit Fees: (� $350/unit - Single Family Residential connecting to existing lateral D $650/unit - Single Family Residential connecting with new lateral $100/unit - Multi, Hotel, Living Units, etc. , Actual Amount: $500/connection - Commercial and Retail Actual,Amount: Connection Use Fees (See Attached Calculation Sheet): Date: i r G � 2_0i7 Final Approval By: Authorized Representative Cupertino Sanitary District Area and Frontage Fees Amount: Residential Excess Fees over 3.5 unittacre Amount: Commercial and Retail Connection Fees Amount: Commercial and Retail Change in Use Fees Amount: Date: i r G � 2_0i7 Final Approval By: Authorized Representative Cupertino Sanitary District CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2016-1677 21103 TAMARIND CT CUPERTINO, CA 95014-1638 (326 08 016) JONATHAN WEI CHIN SU CUPERTINO, CA 95014 OWNER'S NAME: PANDEYANAND KAND POONAM DATE ISSUED: 07/22/2016 OWNER'S PHONE: 408-718-8171 PHONE NO: (408) 255-8999 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class a Lic. #681633 Contractor JONATHAN WEI CHIH SU Date 12/31/2017 X BLDG ELECT _ PLUMB I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing — MECH X 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: CONSTRUCT (1) 2 STORY SFD (3,896 S.F.) WITH ATTACHED I hereby affirm under penalty of perjury one of the following two declarations: GARAGE (480 S.F.), COVERED PORCHES/BALCONY (620 S.F.) 1. 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 (9/22/16) - REMOVE CULTURED STONE AT FRONT OF performance of the work for which this permit is issued. BUILDING, CHANGE WINDOWS, MODIFY DRIVEWAY, REMOVE 2. I have and will maintain Worker's Compensation Insurance, as provided for by BASE OF COLUMN AT THE PORCH ENTRY, CHANGE CRAWL Section 3700 of the Labor Code, for the performance of the work for which this SPACE SIZE TO 24" DEEP W/3" CONCRETE ISSUED 9/26/16 permit is issued. Sq. Ft Floor Area: 4376 Valuations $720000.00 APPLICANT CERTIFICATION 1 certify that I have read this application and state that the above APN Number: Occupancy Type: information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize 326 08 016 R-3 (Custom),R-3 (Custom),U (Private Gar / Ag Bldg),U representatives of this city to enter upon the above mentioned property for (Private Gar /Ag Bldg) inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence l the granting this permit. Additionally, the applicant understands and will comply with all ll non -point PERMIT EXPIRES IF WORK IS NOT STARTED source regulations per, a Cupertino Municipal Code, Section 9.18. WITHIN 180 DAYS OF PERMIT ISSUANCE OR `~ - 180 DAYS FROM LAST CALLED INSPECTION. -Signature Date 9-26-2016 Issued by Abby OWNER -B DFR DECLARATION Date: 07/22/2016 I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: RE -ROOFS: 1. I, as owner of the property, or my employees with wages as their sole All roofs shall be inspected prior to any roofing material being installed. If a roof is compensation, will do the work, and the structure is not intended or offered for installed without first obtaining an inspection, I agree to remove all new materials for sale (Sec.7044, Business & Professions Code) inspection. 2. I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). Signature of Applicant: I hereby affirm under penalty of perjury one of the following three declarations: Date: 9 26-2016 1. 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 ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER performance of the work for which this permit is issued. 2. I have and will maintain Worker's Compensation Insurance, as provided for by HAZARDOUS MATERIALS DISCLOSURE Section 3700 of the Labor Code, for the performance of the work for which this I have read the hazardous materials requirements under Chapter 6.95 of the permit is issued. California Health & Safety Code, Sections 25505,, 25533, and 25534. I will 3. 1 certify that in the performance of the work for which this permit is issued, I maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the shall not employ any person in any manner so as to become subject to the Health & Safety Code, Section 25532(x) should I store or handle hazardous Worker's Compensation laws of California. If, after making this certificate of material. Additionally, should I use equipment or devices which emit hazardous exemption, I become subject to the Worker's Compensation provisions of the air contaminants as defined by the Bay Area Air Quality Management District I Labor Code, I must forthwith comply with such provisions or this permit shall will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and be deemed revoked. the Health & Safety Code, Sec 225505, 25533 and 25534. . APPLICANT CERTIFICATION C. Owner or authorized agent: . --- I certify that I have read this application and state that the above information is Date: 9-26-2016 correct. I agree to comply with all city and county ordinances and state laws CONSTRUCTION LENDING AGENCY relating to building construction, and hereby authorize representatives of this city I hereby affirm that there is a construction lending agency for the performance to enter upon the above mentioned property for inspection purposes. (We) agree of work's for which this permit is issued (Sec. 3097, Civ C.) to save indemnify and keep harmless the City of Cupertino against liabilities, Lender's Name judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands Lender's Address and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. ARCHITECT'S DECLARATION understand my plans shall be used as public records. Signature Date 9-26-2016 Licensed. Professional VA CONSTRUCTION PERMIT APP4 CAT ON " COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildfncl cpc ertino.org - �r < E 11\ piv r,r)mm T l('i'1(1N' m s11lr1TTTf m I I A T TGA A -111111 f -fT DrSncinht env- n rn i Z. 77 PROJECT ADDRESSfi ` �'�'y, ,y►�(► y ri r y� r dr. 1 • �� � - �/ t4i �- ( t APN lrj l I I"r ,� (�V .t" :317'C%/' V 0WNERNAME A H vC1 S4 �ri 69 !1 JS G PHONE 0 ^I^ Y a7 '7' 7°I( E-MAIL acLitt s STREET ADDRESS 2-1103 f"t1� til CITY, STATE, ZIP ♦ g - FAX CONTACT NAA9E _, .. •do o A v 4- S Y% PHONE T y 8 0-A b v . C Cj SI'REETADDRESS �f P (^ — 1 � � . � �} F •3� fiJTY: STATE, LIP G � t' i TI C A J 6 f 4- FAX ❑ OWNER. ❑ OWNER-BUIIAER ❑ OUR.ERAGENT. ❑ CONTRACTOR ❑ CONTRACTORAGENT ❑ ARCHITECT 13 ENaIN ER' ❑ DEVELOPER ❑ TENANT CONTRACTORNAM£ UCENISENILINBER LICEId$ETYP£ BUS. LIC '� 2.7721-3 COMPANY NAME 01m FS. ST G *P L' ld yl f' A V I- f Ui4, G -MAIL FAX STREET ADDRESS 10 ti,r f+o) !y 'i. e cy\ o Ue- CrIY, STATE. ZIP � � i� �� � Jttt �{�jy�Ut 1 rtJ+ PHONE AIZCHIPECTIENGINEIRRTAJuI£ LICENSE NILMBER } 2.& .0 BUS.L]C0 . � COMPANY A'AME i"7 MC fA %"S a,7-,(r�Ge- EwMAIL�-K�l�'-C rk. 0,1 Ind " cow FAX STREET ADDRESS � '� � � � � t f �� �c} �� t1()� � L CITY, ATE, 71P PHHONE f WJ 4+4 94 —2s, ',-IJ�SC-.,'zliTiClr'-0•F-1i.Q'I�--� .; _._.���.-� ��f'�"�y9 --�_.-___,. ��-��__ST ' EXISTING USE PROPOSED USE CONSTR. TYPE as STORY -S J USE MIS OCC. SQ.FT. VALUATION (S) � � EXISTO NEW FLOOR AEMO TOTAL AREA AREA AREA NET AREA - -� BATHROOM KJTCHEN OTEEL REMODELAREA R.EMODL-L AREA REMODEL AREA POF:CI3.AREA DECKAf2F:A TO TALDECI€,PORCHAREA I GARAGlAR):A: []DETACH ❑ ATTACH DwYLLING UNITS: D DINT ❑ YES SECOND STORY El YES BEING ADA ED? nNO ADDITION? ❑NO PRi-APPLICATION AYES 11"ITS, PROVMr COPY OF " IS T'HE BLDG AhT❑ YES PLANNING APPL.R NO PLHMIANIG APPROVAL LETTER EICHLER HOME? E NO RL iVE B1 � � - TOTAL VALUATION: .❑ Aye-• By my signature below, I certify to each of the following: I am the property owner or authorized agent ta act on tht property owner's behalf. I have read this application and the information I have provided is correct. I have read the Description of Work and verify it is accuratre. I agree to comply with all applicable local ordinances and state laws relating to build ng const action. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes. Si watare cf ApplicantlAgent: _ Date: SUPPLEMENTAL INIFORAdA.T1ON REQUME-D— .`�-;:x.:;•:PL.A_N Drew SFD or N4ultifaraily wr-1313Y I3 dllitt S: Apply for demolition permit for g 13 O� ER T'I7E-COiJ?�3'ER ❑ $IITiDI1G PL.$'N RE)THTS existing buildin8(s). Demolition permit is required prior to issuance of building x -_� _28%- pe.nnit for new buildittg. fl tPJiFss l] Pi�>`nIJ.C�L� RE�Ir yr Colurnercial Bldgs: Provide a completed Hazardous Nlatel jals Disclosure [3 sT! \nARn � PtBrac �5 oitl s _ form if ally Hazardous h4aterials are beim used as pact of this project. fl LtRc�:°, — 1] FiREDErT - Copy of planing Approval Letter or Meeting with PIannino prior to h 47GR S4AITAR] SE1i ERDISTRICT submittal of Builditlg Permit application. .-.:- BIclgApp 2011.doerevised 06121111 e�in_ Jonathan Su Homestead Construction 10080 Stern Ave. Cupertino, CA 95014 Spet. 26th, 2016 To whom it may concern, I, Jonathan Su, authorize Calvin Lung to sign for the revision and pick up the approved plans. Sincerely, nathan Su ( 08) 716 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2016-1677 21103 TAMARIND CT CUPERTINO, CA 95014-1638 (326 08 016) JONATHAN WEI CHIH SU CUPERTINO, CA 95014 OWNER'S NAME: PANDEYANAND KAND POONAM OWNER'S PHONE: 408-718-1718 LICENSED CONTRACTOR'S DECLARATION License Class B Lic. #681633 Contractor JONATHAN WEI CHIH SU Date 12/31/2017 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: 1. 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. I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct. i agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the. Cupedino Municipal Code, Section 9.18. Signature,—''Date 7122/16 OWNER -BUILDER DECLARATIO I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 1. I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) 2. I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three declarations: 1. 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. 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 permit is issued. I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If, after making this certificate of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and "expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature Date 7/22/16 DATE ISSUED: 07/22/2016 PHONE NO: (408) 255-8999 PERMIT INFO: X BLDG —ELECT —PLUMB MECH X RESIDENTIAL _ COMMERCIAL JOB DESCRIPTION: CONSTRUCT (N) 2 STORY SFD (3,896 S.F.) WITH ATTACHED GARAGE (480 S.F.), COVERED PORCIIESBALCONY (620 S.F.) Sq. Ft Floor Area: 4376 1 Valuation: $720000.00 APN Number: Occupancy Type: 326 08 016 R-3 (Custom),R-3 (Custom),U (Private Gar /Ag Bldg),U (Private Gar / Ag Bldg) PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by: SEAN HATCH Date; 07/22/2016 RE -ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. Signature ofApplicant: Date: 7/22/16 ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE Ihave read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal. Code, Chapter 9.12 and the Health & Safety Code, Sections 2 05, 2 .25534. f Owner or authorized agent Date: 7/22/16 CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Address ARCHITECT'S DECLARATION I understand my plans shall be used as public records Licensed Professional CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 CUPERTINO {408} 777-3228 FAX (40$) 777-3333 • buildingc@cupertino.org 1 r z'o � NEW CONSTPUCTION ❑ ADDITION n ALTERATrnN/TI r RFVICInN/nFFFIZIZFn namultAl 1)FRnAITiI PROJECT ADDRESS OWNER NAME, • I ('� E-MAIL STREET ADDRESSsAry j�,,� CITY, STATE, ZIP ` FAX CONTACT NAMk. _ l PHONE - F -MAIL - P1h.e,_-'k-9A f STREET ADDRESS CITY, STATE, ZIP - _ RAX ttz .11 OWNER ❑ OWNER -BUILDER El OWNER AGENT ❑ CONTRACTOR ❑. CONTRACTOR AGENT •4 ARCIi TI'L'L' ❑ ENGINEER ❑ DCVBLOPER. ❑ TENANT CONTRACTOR NAME 71 LICENSE NUMBER LICENSE TYPE BUS. LIC B COMPANY NAME F -MAIL FAX STREET ADDRESS CITY, STATE, VIP PHONE- ' ARCHTTFCT/F NGINrLR NAMLL.ICF.NSE NUMBER BUS. LIC 4 ' 2 2, O COMPANY NAME - F-MAiL _ FAX STREET ADDRESS CITY, STATE„ ZIP PHONE DESCRIPTION OF WORK - // �-y o V � J A EXISTING USE - PROPOSED USE CONSTR.'I'YPI: 11 STORIES - �,� US F. TYPI? OCC. SQ.F'F: EXISTG AIiF.A g L \ NEWDL•MO ARf rj: ;�� fq f a ARF,AZ)"'7 10'1'Al_ NRT AREAn./�BAT TVALUATION($) ROOM' KITCH1T1V-C.REMODELAREA RI;MOf)rtI. AREA RL:MODILLARIAdf V ot'T PORCH AREA. DBCK.ARL•A 'TOTAL UL'CKIPORCIi AREA GARAGE ARBA: DE'I'ACI[ - ACH ��-'yy /� PATTACH r� &0%;00b._ #. tIWELLUNITS: IS A SF.CONDUNIT SRCONDSTORV5 _ BEING ADDED? []NO ADDITION? LINO - PRE -APPLICATION V9L'S IFYLS,PROV1DL(,'O i)F 1S'1'HL BLDG AN 0Y'.' RECEIVED BY: - TOTAL VALUATION: PLANN[NG.APPL# FIND PLANNING APPROVAL LETTER EICHLER HOME? O - Q opert hs beha f. 7I)ave read this By.Iny signature below, I certify to each of the following; 1 am the property owner or autht)rized a t to act0-leR application and the information I have provided is correct. 1 have read the Description of Work and verify ' a to ogmply with all applicable local ordinances and state laws relating to building construction. I authorize representatives of Cupertino to el -iclenti#ierd property far inspection parpases. Signature of App--licant/Agent: 5 I _.f. Date: X24214 SUPPLEMENTAL. INFORMATION REQUIRED PLAN CHSCI(TYPF ROUTING SLIP New SFD or Multifamily dwellings: Apply for demolition permit for[] existing building(s). Demolition permit is required prior to issuance of building Ov> R-TIIF-cclotv'rFr; UILDING PLAN REVIEW GGG permit for new building. ElFXPRFSS PLANNING PLAN REVIEW _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ANDARU IIBIAC WORLtS form if any Hazardous Materials are being used as part of this project. El LARGE. _IRE DEPT _Copy of Planning Approval Letter or Meeting with Planning prior to ❑ submittal of Building Permit application, MAJOR - SANITARY Slitii'TdR DISTRICT El ENviRoNI%-xFNTALIIr•<ALTH BidgApp_2011,doc rel+ised 06121111 CAPER ENGINEERING INC. PO BOX 14198, FREMONT, CA 94539 Tel: (510) 668-1815 Fax: (510) 490-8690 Project No, 10532 August 24, 2016 Building Department City of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3232 Subject: Proposed New Residence at 21103 Tamarind Ct. Cupertino, CA SITE DEMOLITION, GRADING OBSERVATION REPORT Dear Sir: Per your request, CAPER ENGINEERING INC., has provided observation service for site demolition, primary and final grading. On the basis of our observation and testing, we conclude building pad, compaction operation were performed in general accordance with recommendations of site soil engineer and compacted to a minimum of 90% relative compaction. Prior to grading, demolition of the site has been completed. Any tree root system, debris or trash are encountered have been removed and were performed in accordance with recommendations of soil report. If you have any questions, please contact our office at your convenience. Very truly yours, CAPEX ENGINEERING INC. Gary su, P.E. Principal CAPER ENGINEERING INC. PO BOX 14198; FREMONT, CA 94539 Tel: (510) 668-1815 Fax: (510) 490-8690 Project No. 10532 August 24, 2016 Building Department City of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3232 Subject: Proposed New Residence at 21103 Tamarind Ct. Cupertino, CA FOOTING EXCAVATION (GRADE BEAMS & SPREAD FOOTINGS) AND PREPARATION OBSERVATION REPORT Dear Sir: CAPEX ENGINEERING INC., has provided inspection service for footing excavation and preparation. Footing depth and width were excavated adequate in accordance with approved foundation plan and specifications. The exposed soil conditions of excavated foundation are beyond design bearing capacity and acceptable. Any questions, please call our office at your convenience. Sincerely, CAPER ENfHNEERING INC., Gary H u,"P. Principal QQ,p ESS1ON co a fi 'oF VAW .i FILE WEC and Associates, Inc. August 18, 2015.% City of Cupertino Community Development Building Division 10300 Torre Avenue Cupertino, CA 95014-3202 Subject: Survey Report 21103 Tamarind Court Cupertino, CA -Unit 1 To Whom It May Concern: This letter is to confirm in writing that WEC and Associates, Inc provided a staking survey for the foundation line on the subject property. The stakes have been placed in accordance with the plans approved by the City of Cupertino both horizontally and vertically. The horizontal control is established by the county recorded tract map(s) and/or Record of Survey(s) and. the monument line established along Flora Vista Avenue. We subsequently paid a site visit on 8/17/2016. Froin our professional point of view, the contractor formed the foundation walls in accordance with the horizontal setback requirement as shown on the city's approved plan. The finish floor elevation, based on the top of form measurement, is 102.5. We make no warranty, expressed or implied, as to the services rendered. except that our services are performed in a manner consistent with that degree of care and skill ordinarily exercised by members of the same profession currently practicing under similar circumstances at the same time and in the same or similar locality. If you. have any further questions regarding this matter, please contact me at your convenience. Sincerely, WEC and Associates, Inc. Yi-Ran Wu, PE., LLS LN, 2625 Middlefield Road 4658 • Palo Alto, CA 94306 • Tel: 650-823-6466 + Fax: 650-887-1294 t r 1, 0 1. O CD O 1 i 1 1 _ 1 QE Q Iua � 1 zi 1 1 _ D=60'09'40" L=42.00' "h R=40.00' S.0°03'55"E. 163.25' UNIT 2 FF= 102.5 STAKING DIAGRAM W C 2625 MIDDLEFIELD RD #658 TEL: (650) 823-6466 21103 TAMARIND COURT & ASSOCIATES PALO ALTO, CA 94306 FAX: (650) 887-1294 CUPERTINO, CA Feb 8 2017 City of Cupertino Building Division Attn: Building Inspector_ 1623Wright Avenue Sunnyvale Ca 94087 Ph#: 408-735-1524 Fax. 408-733-1548 Subject: 21103/21101 Tamarind Ct, Cupertino Ca, Pandey Residence. Final Framing Observation by EOR MHA Consulting Engineers Inc, Dear Sir, Date: 2-8-17 2,00 pm On this date, final framing observation for the above project was performed by MHA Consulting Engineers Inc. We find that in general the overall framing and construction is substantially in conformance with the approved plans and specifications. We approve of the final structural framing and construction of this project. MHA Consulting Engineers Inc. tef(OFESsz, 4 4-J-0 M.B. SEE TABLE EVENLY SPACED STAGGER EVENLY M"'�P NLY ACED STAGGER T -7 0 0 r:4 m f7l © 0 I Jry n SIDE PL (2 REQD, BOTH SIDE) LL- A500 Grd R < ry STEEL BRACKET FOR FLUSH BEAMS AT EXT WALL DETAIL (BEAM 2B2 & 2B10) F4—J' M.B, EACH SIDE "6qx18'xi'- SIDE PL (2 REQD, BOTH SIDE) A500 Grd B .005850.2 Exp. Ia/31/18 C I v x STEEL BRACKET FOR HIP BEAM LRB3 Mr. A.Y. nm 21103 TAMAR= Cr MW : NIX MHA CONSULTING ENGINEERS Inc cup cAlmm" mv. 0 1025 WONT AVEM, SUMMAW CA "M PAMNY RIMUM 408-735-1524 STUqjffW PIATS rOR P107CM 1623 Wright Avenue Sunnyvale Ca 94087 Ph#: 408-735-1524 Fax: 408-733-1548 February 8, 2017 City of Cupertino Building Division Attn: Building Inspector- Subject: nspectorSubject: 21103 Tamarind Ct, Cupertino, Ca. Pandey Residence Epoxy Hold Down Installation Observation by MHA Consulting Engineers Inc. Date of Observation: 02-8-17. Time* 2.00 p M. On this date, we observed the epoxy installation of Hold Down Anchors for the above project," 5/8" dia rods were installed and embed 18" for HDU5, 12.5" for HDU2 using Set -XP- -epoxy. All rods were Installed in conformance with manufacturer's specifications and approved plans and specifications. If you have any questions please call. Yurs Sincerely MHA Consulting Engineers Inc. 0-3 Feb -1, .7 Qity'61.'.Cupe [ rt' no Builcfirig sion Attn: Buildin 'spector: V in 4S,/Zo (6 c/6 `77 162.3 Wright.Avenue:., Sunnyvalieta 94087 Ph#.: 408735-1524: Fax 46.8-7334548. _SubjivCt l1.03/214011 Tamarind Ct-Cupertino :-Ca,.Pandey Residende F ilfia(Framirig Ob'___:b'EORMHAC­onsultingf E servation y. _�:ng%neom:nc. bear Sit, Date: Z-1-3717-12,'00 pm.. On his date, final -framing observation -for the above project was 'Cperfbrrned� MHA ongui t *_ .: : � I ­ I ' ­. . by #ng, Enlgjn6er.S.: Inc.. We: find that in general the overall- Irato g: :an construction is. substantially In conformance with: the: approved planstinct :s Pecifications, Me approve- of the' final structural .fra-iming and c6instructioncif this-,roject; p ITEMS- REQUIRING REMEDIAL WORK(NONE TBLANK). Avec 'notched :Teams ,,.ib,lhst-ajf.stetl.,pl'ate brackets see attached SK -1. Ver i ied'Ty e C sb6rwail nailing conforms With specifications. 111):M: Studs Frith finch diameter pipe penetreition is ��tilladequate. . . .............. . ...... Th s Q sWwall in,this location of are not -part of a h 11 and h6t earwa -heavily loaded; MHA -Consulting lIngineers:Inc.. Ot"VA OF CUP'ERTINO CONTRACTOR / SUBCONTRACTOR LIST Building Department City Of Cupertino 10300 "Tone Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 Fax: 408-777-3333 ..... ...... JOB ADDRESS 21103 TamarindCt., _ PERNMIT:#2016A677, —V -- OWNER'S NAME Anand & Poonam Pandey....__.__...__...._._.........._..._. GENERAL CONTRACTOR: Construction, Inc. PHONE # .. BUSINESS LICENSE 9'�_ ADDRESS: 10080 Stem Ave CITYIZIPCODE:Cupertino, CA 95014 ] / *Our municipal code requires all businesses n=orking in the city to nave a 4...rty or 4.rrperc1r10 DUNU ass ItCV113W. 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: er ; Contractor Signature 06/26/17 Date SUBCONTRACTOR BUSINESS AME ....... ..... _..... _.._._...... ..... _�__ .._..._.___....._.__.... BUSINESS LICENSE # 1 ............. . Cabinets & Millwork Niviya Cabinets �7 l Cement Finishing Electrical k Katherina D7rat 40297 -.._... - - ..................... Excavation _ - Marcelo Hauling 9 .._ _ Fencing Flooring / CarpetingGolden-Hardwood Floor 40654 .-A/ _.._.._...---- _ _ - Linoleum / Wood Glass / GlazingSo .__._ ............. _.... _.._.......... Bay Shower Heating All Fresh Temp 35602 Insulation —.._....._..._..__..____.__........ Barreras Insulation__..__.._.----..._..._._......--._---_._...__...—_.... A/0 Marcelo Hauling Grading--__— _.-Landscahtng...__........_...._......__ Lathing _ - - ...._..--- Masonry . V-_0 -. ---- -. Painting / Wallpaper Paving Ms Construction – 31031 Plastering ..... _ . ---- - - --. _. _.. ...... ..--_....... . ...... I ----- Plumbing -- _...... --- ----...... Peninsula Fire Protecting Inc ( 3 �Q Roofing i Septic Tank Sheet Metal Sheet Rock Tile er ; Contractor Signature 06/26/17 Date CONTRA CTa)R./ SUBCONTRACTOR LIST Biffldhilg Department City Of Cbp�r.tfila 1:030()'1' , i - I MV. 2 A, N"WLM: C'uf�4600, CA 9504-4739-5$ T( . Ji ' I h6he40.8-777 322& F-ak: 4W-777 5333 21103 Tamarind Ct., ........................ ........... . PFR M# 20161677 . .... . ........ 7 OV.,.NTr�R""�'i\fAM� E::Anand & Poonarn Pandey' ..... .... . . . . ............... . .. . . .. . . ............. . .. . . ........ . . ..... . . ....... . ....... Gy r -RAI, C0N`rRAU.f'OfZ-- Homestead Construction, Inc. .............. . .... ... . ...... . . .............. - IRIT&INESS LICUNSr'�, 406743 ADDRU',SSA0080 Stern Ave Cupertino jj ,,CA 95014 CITY/71PCODE.�.. . . ........ "'Our municipal coeter?'quares.all bwirw� ies vvorkiq,- In he city w hiwe:a (`lt"v of Cup ar.0.00 btlsfile'ss llcc,'11140; K.0 BUILDING'. YINNAL OR FINA-111., OCCU RANCYVNISPE.C'17-10NI(S), WIL4, BE: 'SCHEDUTLI . U1.14TIL THE 0,,* ENKRAL C6.)NITRAQ1 .'GR A" ALL SUMCC! N'TRACTORS HAVE 0,131'.41NEDA CITT' OF;CAWE - RUNG, :B LICE .0SINESS �'NSE,. .1 aniii t" tising:any gtebconlractqxi Rate Pfease check: and co.m.p lete-the . . . ........ ................ "SO.B(--'O,*,N't�]kAC-.�i:*.o�R B 1'1 _NIE S S NA E, BUffiNESSl,"WENS E 4:1 ... . ................ . ........ .... . ...... . . ......... Cabinet i &Avfiftivork ...... . ..... .. ... ..... .. . .. Commit Fin,ishing ...... ..... . . . . .. . . . . . ............. .. . ...... ..- Excavat, -t Marcelo Hauling & Gpe' 403139 . ............. . .......... ..... Fencing . . ........ Floo 11 carpetilig ....... . ....... . . ............ . ... . ........... . ........ . . ..... ......... ... Qlass /Glazilig . . Q ating ........... . ...... . ............ ............. . ....... . ... All Temp 401857 . . . . . . . ............. . ............ . . . ...... . ..... ------------- buldsca, g pul - - - - ----- - ------ ------------ . .. . ....... *'"*'*** .................. ­ ..... ................... . .............. ........ ....... Marcelo Hauling & Grading 40 3139 ............... .... . .. 4sonfy _.W.._.........._. .... . .... . .. . ..... . ...... . . ....... MS Construction 494-149 Pain,61101 -Wal1pper T Q ;aNdtig Ms Construction ' 4.0449,f7 I Lplasicring . . . .................. . . . . ........... . . .......... ........... . ..... . . . ...... I Tfumhing Peninsula Fire Protecting Inc 401504 : S, .1 � A , peptic ;A1.1k, Sbea Wtal ..... .... . ........ Sheet Rock 1110 07/31/17 .... .... . ..... Date CERTIFICATE OF VERIFICATION CF3R-MCH-20-H Duct Leakage Diagnostic Test _ (Page 1 o 3 ) Project Name: Pandey Residence Enforcement Agency: City of Permit Number: B-2016=1677 Space Conditioning System Location or Area Served Cupertino 04 Duct Leakage Test Condition Dwelling Address: 21103 Tamarind Ct. City: Cupertino Zip Code: 95014 A. System Information 01 Space Conditioning System Identification or Name System 2 02 Heating Capacity (kBtu/h) 58 02 Space Conditioning System Location or Area Served second story 04 Duct Leakage Test Condition Test final 03 Building Type from CF -1R Single family �jT 06 Leakage Factor 0.06 07 04 Verified Low Leakage,pucts in Conditioned Space No, credit is not taken Measured AHUAirflow (VLLDCS) Credit from CF1R? 09 05 Verified Low Leakage Air Handling Unit (VLLAHU) Credit No, credit is not taken Actual duct leakage rate from leakage test measurement (cfm) from 'CF1R? 11 06 Duct System Compliance Category Ne MCH -20a -Completely New. Duct System; , B. Duct Leakage Diagnostic Test 01 Condenser Nominal Cooling Capacity (ton) 0 02 Heating Capacity (kBtu/h) 58 03 Conditioned Floor Area served by this HVAC system (ft2) 1948 04 Duct Leakage Test Condition Test final 05 Duct Leakage Test Method Total leakage 06 Leakage Factor 0.06 07 Air Handling Unit Airflow (AHUAirflow) Determination Method Heating system method 08 Measured AHUAirflow 'This field or section is not applicable 09 Calculated Target Allowable Duct Leakage (cfm) 76 10 Actual duct leakage rate from leakage test measurement (cfm) 70 11 Compliance Statement System passes leakage test Registration Number: 217-A0266884A-M2000003A-M20A Registration Date/Time: 2017-08-03 15:28:58 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.008 Report Generated: 2017-08-03 15:28:41 2013 Residential Compliance Schema Version: 2013.1.007 CERTIFICATE OF VERIFICATION CF3R-MCH-20-H Duct Leakage Diagnostic Test (Page 2 of 3 ) System was tested in, its normal operation condition. No temporary taping allowed. B. Duct Leakage Diagnostic Test 12 Notes All supply and return register boots were sealed to the drywall. C. Additional Requirements for Compliance 01 System was tested in, its normal operation condition. No temporary taping allowed. 02 Outside air (OA) duct connections to the central forced air duct system shall not be sealed/taped off during duct leakage testing. OA ducts used for Central Fan Integrated (CFI) Indoor Air Quality ventilation systems, or Central Fan Ventilation Cooling Systems, that, utilize dampers that open only when OA is required and automatically close when OA is not required, may configure the OA damper to the closed position during duct leakage testing. 03 All supply and return register boots were sealed to the drywall. 04 Building cavities were not used as plenums or platform returns in lieu of ducts. 05 If cloth backed tape was'used it was covered with Mastic and draw bands. 06 All connection points:'between the air handler and the supply and return plenums are completely sealed. Visual Inspection at Final Construction Stage_(applicable if system was tested at rough -in) After installingthe inte , .. ' ec Dior �finishmg wall and verifying that the above rough m tests was completed the following procedure must be performed 07 For all supply and return ,registers, verify that the spaces between the register boot and the interior finishing -wall are properly sealed., O8 If the house rough -in duct leakage test was conducted without an air handler installed, inspect the connection points between the air Handler and the supply and return plenums to verify that the connection points are properly sealed. 09 Inspect all joints to ensure that no cloth backed rubber adhesive duct tape is used. 10 Verification Status` Pass 11 i Correction Notes for this table The responsible persons signature on this compliance document affirms that all applicable requirements in this table have been met unless otherwise noted in the Verification Status and the Corrections Notes in this table. D. Determination of HERS Verification Compliance All applicable sections of this document shall indicate compliance with the specified verification protocol requirementsoer for this Certificate of Verification as a whole to be determined to be in compliance. 01 I Complies: All specifiedyerification protocol requirements on this document are met. Registration Number: 217-A0266884A-M2000003A-M20A Registration Date/Time: 2017-08-03 15:28:58 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.008 Report Generated: 2017-08-03 15:28:41 2013 Residential Compliance Schema Version: 2013.1.007 . t r CERTIFICATE OF VERIFICATION CF3R-MCH-20-H Duct Leakage Diagnostic Test (Page 3 of 3 ) Documentation Author's Declaration Statement 1. 1 certify that thisCertificate of Verification documentation is accurate and complete. Documentation Author Name: Darrel Kelly��t�LP�/C Documentation Author Signature: Company: Date Signed: Builders' Energy Services, Inc. 2017-08-03 15:28:58 Address: CEA/ HERS Certification Identification (if applicable): 1478 Bird Avenue City/State/Zip: Phone: San Jose CA 95125 408-202-9075 Responsible Person's Declaration statement I certify the following under penalty of, perjury, under the laws of the State of California: 1. The information provided on this Certificate of Verification is true and correct. 2. 1 am the certified HERS Rater who performed the verification identified and reported on this Certificate of Verification (responsible rater). 3. The installed features; materials, components, manufactured devices, or system performance diagnostic results that require HERS verification identified on this'Certificate'of Verification comply with the applicable requirements in Reference Appendices RA2, RA3, and the requirements specified on the Certificate of Compliance for the building approved by the enforcement agency. 4. The information reported on applicable sections'of the Certificate(s) of Installation (CF2R)'signed and submitte'dby the persons) responsible for the construction or installation conforms to the,requirements`specified on the Certificate(s) of Compliance (CF1R),approved by.the enforcement -agency. 5. 1 will ensure that a registered copy.of this Certificate of,Ve'rif cation shall be posted, or made^available with the building permits) issued for the building, and made available to the enforcement agency for all applicable inspections I understand that a registered copy of this Certificate.of Verification is required to bef q ;included with the documentation the builder'provides "to the building owner at occupancy. Builder Or Installer Information As Shown On The'Certificate Of Installation' Company Name (Installing Subcontractor; General Contractor, or Builder/Owner): JONATHAN WEI CHIH SU Responsible Builder or Installer Name: CSLB License: Jonathan Su 681633 HERS Provider Data Registry Information . Sample Group Number (if applicable): Dwelling Test Status in Sample Group (if applicable) , Tested HERS Rater Information HERS Rater Company Name: Builders' Energy Services, Inc. Responsible Rater Name: Darrel Kelly Responsible Rater Signature: `2`!W�//� Responsible Rater Certification Number w/ this HERS Provider: Date Signed: CC2005655 2017-08-03 15:28:58 Digitally signed by CaICERTS. This digital signature is provided in order to secure the content of this registered document, and in noway implies Registration Provider responsibility for the accuracy of the information. Registration Number: 217-A0266884A-M2000003A-M20A Registration Date/Time: 2017-08-03 15:28:58 HERS Provider: CaICERTS' CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.008 Report Generated: 2017-08-03 15:28:41 2013 Residential Compliance Schema Version: 2013.1.007