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02100021CHTY OF CUPERTEA �.� �j7� ��� �T1T m�1T 1T 1T 1�T FORM GA � 1� �- cirroF PIE IR\171 ET APP L�ECAT1LO ll` ®1iOlV'1L CUPEI HNG APN # Yee Descri floe Date: BAPPLOTHER Buildir g Address: MECHANICAL BCONSTAX Construction Tax BUILDING BCONSTAX Owner's Name:G BUILDING Phone #: • J ►3� �'�t �t �- U, Con BCONSTAXR License #:346 46 22 BUILDING BELEC 1000 Elec 600V <=1000A ELECTRICAL BELEC 1001 Contact: — ELECTRICAL Phone Elec Svcs 600V <= 200A ELECTRICAL B]EN ERGY Energy S Applicant/Contrac . Energy Add Multi Fax #: BINVESTIGA u' iri Permit Info: BUILDING BMITIGATC Bl�dj Elect Plu Mech BMITIGATR Job D scription: 2 C�. �Lo ,ter BMNEWMULTI esidential: Co ercial: BNEWMULTI Sq.Ft. Flo Area ELECTRICAL $/Sq.Ft.: New Comm Electric • Architec gineer: BNUCONMV! Valuation: MECHANICAL Type of Construction: % ( Occupancy G up: r Quantity Yee ED Yee Descri floe Yee Groan BAPPLOTHER Other Appliances MECHANICAL BCONSTAX Construction Tax BUILDING BCONSTAX Ind/Off/Comm/Quasi BUILDING BCONSTAXBQ Con. Tax for BQ Zone BUILDING BCONSTAXH Hotel and Motel BUILDING BCONSTAXR Constax — Resi/Mobile BUILDING BELEC 1000 Elec 600V <=1000A ELECTRICAL BELEC 1001 Elec 600V > 1000A ELECTRICAL BELEC200 Elec Svcs 600V <= 200A ELECTRICAL B]EN ERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING BMITIGATR Res. Housing Mit Fee BUILDING BMNEWMULTI New Multi -Family Res MECHANICAL BNEWMULTI New Multi -family Res ELECTRICAL BNUCOMME New Comm Electric • ELECTRICAL BNUCONMV! New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING 1 of 3 b ��' 3 d _.,.._........... ....._ .. _._ ..._._.. _...., .....,.,, f CITY OF CUPERTINO CITY of PERMIT APPLICATION FORM CUPEkIN0 Quantity Fee ED Fee Description Fee Group BNUMULTI New Multi -family Res PLUMBING BOVERTIIVIB Ins ection Overtime BUILDING BPBACKFLOW Atmospheric Vacuum PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPFIXTURE Pb1g Fixture PLUMBING BPGAS Gas Piping System Fee PLUMBING BPINTERCEP Ind Waste Interceptor PLUMBING ZPLANCHK Plan Check Fee BUILDING )3PLANCKADD Plan Check Add Multi BUILDING BPLANCKREP Plan Check Repeat Fee BUILDING BPREPIPE Re i e Of Fixtures PLUMBING BPSEWAGE Sewage Disposal PLUMBING BPSEWER Sewers PLUMBING BPSPR NK Lawn S rinkler/Backflo PLUMBING BPSTORM Stomi/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT Alt of Drain & Vent PLUMBING BPWATER Install/Alter Water Pie PLUMBING BPWHEATER Water Heater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection, Fee BUILDING BREMACOVER A/C Unit > 10,000 cfin MECHANICAL BREMAIRHAN A/C Units <=10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIIXT Lighting Fixtures ELECTRICAL BRENT RN Relocation of Furnace MECHANICAL BRENIFURNOV Relo Furnace > l OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL BREMNRAPP Rem Non -Res Appliance ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL BREN'IPOWER Power Device/Apparatus ELECTRICAL BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Heating MECHANICAL, BREMRESAPP Remodel Res Appliance ELECTRICAL BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Sips, Marquee ELECTRICAL BREMTHEATR I Theatrical Lighting Fix ELECTRICAL CITY OF CUPEWrINO BUILOIN'c DIVISION PERMIT CONTRACTOR INFORMATION s Bu f-119c9k9gHS.1,A MAR DR MINORU & MARIANNE TOGAMI PERMITN(n0uV/ 2cD1B00021 1A"RU & MARIANNE TOGAMI APPL"ATl1'®1`J/2002 iONI:: SANITARY NO. CONTROL NO. ARCIIIIECTIENGINHERc BUILDING PERMIT INFO BLDG ELECT PLUMB MICH LICENSED CONTRACTOR'S DECLARATION 1 nerenr, affirm mal I.. licensed oder pnwkdons of Chirac,9 eenmmencing ADD hh� ll 250 S FT J 1C1��C� & FAMILY RM Q With Section 7gaB of Division 3a1 Ne Busin'9�up rnfcesinmCudc,andmyliccnsis in lull linMaW'cffcd ss ��IVALED� License Clu Lie✓ ' Uate Contra 1 understand my mall used as lic recd APR 2 4 2003 plans public Licensed Pndci sional OWNER. BUILDER OWNER-BUILDERON DECLARATION Ce , ^,AG m Contractor's 1 hereby ailirm that 1 from We Licenu law for the BL X71;TSJiJU fallowing reason. (Section 7031.5, Business and Professions Codd: Any city lir county which requires a permit to construct. alter, improve, demolish, or repair any swnure prior to its issuance, also requires (be applicant for such permitto lite a signed statement that he is licensed pursuant sea the provisions of the Commctor's License law ]Chapter 9 .Y3.6iQr33dA10:0 Valuation (commencing with Section 7000) of Division 3 of the Business and Professions Code) lir that he is exempt therefrom and the basis for Be alleged exemption. Any violation of N-N Occupancy Type P Y YP Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not are man five handled dollars ($50()). lO2 — PIERS I, as owner of the properly, at my employees with wages is their sale compensation, 104 — - REBAR Required Inspections willdothewnrit. end be squcmre is not intended or Offered On aale(See 704L Business nd Professions Code: The Conoocams License Law does not apply to an owner of property who builds or improves thenar, and who does men work himself or through his own emplaycu, provided that such improvements arc not intended or offered for sale. If, 105 — ANCHOR BOLTS however, the (wilding or improvement is sold within one year of completion. me owner. 106 SEWER WATER builder will have the burden of proving that he did not wild or improve for purpose of - & .Jr.). 202 - UNDERFLOOR PLUMBING ❑ I, as owner of the property. am exclusively contacting with licensed contractors to 203 - UNDERFLOOR MECHANICAL construct the project (Sec 70a,L Business and Professions COdet) The Comma mrs Li- mose Lawdoes nor apply manowner ofpropenywho Wilds orimproves rheson,and . 204 — UNDERFLOOR FRAME LicenseL;wufor suchDmjecuwith aconhano MliansedpursuammmcComncmrs 205 - UNDERFLOOR INSULATION I am exempt under Seo. T,B&PC for reason 301 - ROUGH PLUMBING nc,,;r— e o- -oL 302 - TUB & OR SHOWER KE R'S COMPENSATIONDEC ION 303 - ROUGH MECHANICAL Iherch rnnunder pcnahyafperjuryone ohnemllowing dca)entinna: 3O4 — ROUGH ELECTRICAL 1 ]hove send will maintain a Certificate ofConsonuo set binsum for Worker's Compen- sation, u provided for by Section 37110 of the labor Code, for the performance of the - 3 05 - FRAME work far whish Nis permit is issued. 306 — HOLDOWNS ❑ 1 have and will maintain Workers Compensation Insumbec, as required by Section 3 07 - INSULATION 37x1 of the labor Cole, for in. performance of the work (lir which this permit is issued. My Workers Compensation Insurance caner and Pal icy number are: 308 — SHEETROCK cnoj Policy NO.: 309 - EXTERIOR LATH CERTIFI CEXEMPTION COMPENSATIONINSURANCE 31 O 310 — INTERIOR LATH oLissectinn need our he completed ifthep.it is house hundred do)].. nIIXB 311 - SCRATCH COAT orless) 313 - ROOF NAIL 1 citify Ino, in the pe]irminecofthe workfor which this permit is issued. Ishall not of any person in&.nneso r as ha become subject ua the Workeri Compensation 5O1 - FINAL ELECTRICAL ENERGY Laws Wit m 502 503 - FINAL PLUMBING ENERGY - FINAL MECHANICAL ENERGY �TOAPo of EAcmplloa,.yatinnlJ lie the Workers Clcrmakingtnprvisiosol muss 504 - FINAL BUILDING ENERGY forthwith comply beim such Pnrvixinns nr.this permit shall be deemed revoked. ithcomvntheWnrker'sCompensea.%PermiitshallWdemedmvokcd. 505 — FINAL ELECTRICAL CONSTRUCTION LENDING AGENCY I hereby affirm Not there is a construction lending agency lar the periormance of 506 - GAS TEST the work lin which this Permit is issued (Sec 3097, Civ. CJ Lcndct. Name 507 508 - FINAL PLUMBING - FINAL MECHANICAL Lender's Address I certify Nal 1 have read this application and suite that IM shove information is 509 - FINAL GRADE bonding 1 agree to comply wile all city and county ordinances of and store laws relating to building construction, nJ hereby authoria reprcuntativcs of his city to crier upon the 5 FINAL PLANNING move mnudgmoned proPeny liarPurposes. 14 V FINRKS (We) agree to ave, indemnify and keep harmless the City of Cupenum against expensescur expenses which may in any way eacme against said City / ihatalnconsequ consequence Of the loaning Of of the glinting of Isis permit. Aconsequence APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NONPOINT Issued by: aa�S C,A Date LJ SOURCE REGULATIONS. a Re-roofs Type of Roof a limo! Appli- onlracmr Date IAZARDOUS MATERIALS DISCLOSURE Will the PPlicam or fare building occupant umrc lir handle hvmdous material defined by the Cupertino Municipal Code, Chapter 9.13, and the IIcahn and Safely ode, Section 2553200? All roofs shall be inspected to an roofingmaterial beinginstalled. E] No � prior If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant (it future building txcupamuse equipment nrdevices which emit hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection. Di ric17 ❑Yes No I have read the haaNrms materials requiremenu under Cleaner 6,95 of the Culifor- iliallcalth&Safety Crxk.Sminm255115, 25533 nJ2551t.1undersand thatff datimidfn6 Jinx not currently baso a tenant, Not it is my mxporsiM1iliy In notify IM ocupnt of the rtmen6 which thus mel prior WiSSun[c ofa CenifKatrof QTnpnc. /m attire of Apphct ate —19Z Il roof coverings to be Class oBo or better '> crorauth Date 0 0 pp� CITY OF ��II FE.lL\L1�7 RT AP 11�1L1L_.AT1L�'�1�7 FORMCUPEKA D uu Yee IIID Fee IDescri ti®un ]Fee Group BREMVENFAN Vent Fan Single Duct MECHANICAL BREMVENSYS Ventilation Systems MECHANICAL BSCBLVD Scb Specific Plan BUILDING BSIEISMICOM Sellsmic Commercial BUILIDUgG BSIEMMICRE Seismic Fee Res BUILDING &2FAM Single & 2 Family BUILDING �- SFNA Single Family New Add BUILDING BSPECIAL Special Insection BUILDING BSWIM Swimming Pool BUILDING .BTEMP Temporary Power ELECTRICAL BTEMPPERM Temporary Bldg Permit BUILDING BTEMPSVCS Temp Dist Svcs ELECTRICAL BUSLIC Business License BUILDING ELECTRIC Electrical sq foot ELECTRICAL ]EP ERM17 7E]E lERec Permit Issuance ]EL]ECTRICAC. MPERMFEE Mechanicals . foot MECHANICAL FvN EI[BIy HTIFIEIE Mech Permit Issuance MECHANICAL Vj P FIEPI�UTIFIE]E Flumb1mg Permit Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Chane BUILDING BBOILERI Boiler <= 100,000 Btu MECHANICAL BBOILER2 Boiler> 100K to 500K Btu MECHANICAL BBOILER3 Boiler> 500Kto 1M Btu MECHANICAL BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL BBOILER5 Boiler > 1.75 M Btu MECHANICAL 3 of 3 Mee QUO Z rFa Fah OZ22? 0_t-; aOgU 4.0 fyt, ail � p Cnn �XmLL W^u I -z> � i- C U� CITY OF CUPERTINO BUILDING DIVISION PEN '� � t �L M BUILJ)I9C9\_PeES-LA MAR DR MINORU & MARIANNE TOGAMI PERMIT NcO 2 10 0 0 2 1 OwlIgISNA&RU & MARIANNE TOGAMI APPLICATI1W(5`F--�� //q 2 0 02 // 'Ff PHONE: SANITARY NO. CONTROL NO. ARCHITEC IFNGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 LICENSED CONTRACTOR'S DECLARATION I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing ADD 2 5 O SQ FT JgKlels'Rf & FAMILY RM ) with Section 7000) of Division 3 of the Busin ss d Professions Code, and my license is . in full for@earl,cffect. License Cl Lic. Date ContragWr ARCHITECTS DEATf0N 1 -understand my plans shall be used as public records Licensed Professional OWNER -BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License Law for the $50000 following reason. (Section 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure prior to its issuance, also requires the applicant for such permit to file a signed statement rL� rp�.,�,� A 3SM.0 Valuation that he is licensed pursuant to the provisions of the Contracturs Liccnsc law (Chapter9 w�ftrti, rOoO (commencing with Section 7000) of pivision 3 of the Business and Professions Code) or that he is exempt therefrom and tWbasis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permitsubjects the applicant to a civil penalty of i UAPMN DATiOccupancy Type not more than five hundred dollars ($500). 102 - PIERS ❑ 1, as owner of the property, or my employees with wages as their sole compensation. 3 - E IR Required Inspections will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business15 Professions Code: The Contractors License Law does not apply to an and owner of 10 4 - REBAR property who builds or improves thereon, and who does such work himself or through his own employees, provided that such improvements are not intended oroffered forsale.If, 105 — ANCHOR BOLTS however, the building or improvement is sold within one year of completion, the owner- 106 - SEWER & WATER builder will have the burden of proving that he did not build or improve for purpose of sale.)' 202 - UNDERFLOOR PLUMBING 0 1, as owner of the property, am exclusively conuudng with licensed contractors to 203 - UNDERFLOOR MECHANICAL construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li- cense law does not apply to an owner of property who builds or improves thereon, and. 204 - UNDERFLOOR FRAME who contracts for such projects with aconvactor(s) licensed pursuant tothe Contractors icense Law. 205 - UNDERFLOOR INSULATION I am exempt under See. , B & P C for this reason 301 - ROUGH PLUMBING nee to o - - oz 302 - TUB & OR SHOWER RKER'S COMPENSATION DECL ON 303 - ROUGH MECHANICAL 1 hereb itrrn under penalty of perjury one of the following declarations: 304 - ROUGH ELECTRICAL ❑Ihave and will maintain aCertificateofConsenttoself-insure for Worker's Compen- sation, as provided for by Section 3700 of the labor Code, for the performance of the work for which this permit is issued. 306 - HOLDOWNS 0 1 have and will maintain Workers Compensation Insurance, as required by Section 307 - INSULATION 3700 of the Labor Code, for the performance of the work for which this permit is issued. My Workers Compensation Insurance carrier and Policy number are; 308 - SHEETROCK Cart-. Policy No.: 309 - EXTERIOR LATH CERTIFICATE COMPENSATION INSURANCE CEORKERS' 310 — INTERIOR LATH (This section need not becomplctcd if the permit is forone hundred dollars ($)00) 311 - SCRATCH COAT or leas.) 313 - ROOF NAIL I certify that in the performance of the work for which this permit is issued. I shall not employ any person in anvmannerso as to become subject to the Workcrs' Compensation 501 - FINAL ELECTRICAL ENERGY Laws of California. DW nt _ 502 503 - FINAL PLUMBING ENERGY - F I NAL MECHANICAL ENERGY `A,Ipplic TO APPLICANT: 11', after making this Certificate of Exemption, you should be a subject to the Workers Compensation provisions of the Labor Code, you must 504 - FINAL BUILDING ENERGY forthwith comply with such provisions or this permit shall be deemed revoked. 505 - FINAL ELECTRICAL CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency for the performance of 506 - GAS TEST the work for which this permit is issued (Sec. 3097, Civ. C.) 5 0 7 - FINAL PLUMBING Lenders Name 508 - FINAL MECHANICAL Lenders Address I certify that I have read this application and state that the above information is 509 - FINAL GRADE 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 5F I NAL PLANNING above-mentioned property for inspection purposes. 14 FIN W RKS (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which may in any way accrue against said City in consequence of the granting of this permit. ' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: / Date SOURCE REGULATIONS. I Re-roofs Type of Roof '0 a re of Appli ontractor Date AZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety Section 25532(a)? Code ,E]Yes All roofs shall be inspected to any roofing material being installed. E] Yes fel No prior If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or future building occupant use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District? ❑ Yes A No 1 have read the havardous materials requirements under Chapter 6.95 of the Califor-—� niaHealth&Safety Code, Sections 25505,25533 and 25534,1understand that lithe building does not currently have a tenant, that it is my responsibility to notify the occupant of the 'remems which must met prior to issuance of a Certificate of Occupahc . ature of Applic ate O� 11 roof coverings to be Class "B" or better ., true auth nt Date I CAL ULATED BY:.. a.� .... STEv �N A . ARNOLD.... _ . _ JOB. N.UNISER:.. . CHECKED BY.-........ .CIVIL.ENGINEER........ ...... ....... :........ ... ... PROJEC.T:. HFA 7 LUSS . SIGHED. BY: f665:THE.ALAMEDA.SUITE.1.30.....:.......:..........DATE.... q- -OZ, R.C.E:NO:: SRN JOSE,. CALIFORNIA. 95126....... .-SHEET-NO.-OF CERTIFICATE C F CO1Y1 P LIIAN CIE e RESIDENTIAL (Page 1 of 3) (CIF -]IR 7-7 -0L �-17-0Z a Project Title I i I I I Lv e. Project Address A SY'TtA'R W S I.4\ A -T o f 5S7- 9 bo S Document �ti�oYtCAu�th�� Telephone Compliance Method (Package or Computer) Climate Zone Building Permit # Plan Check / Date Field Check / Date n orccment Agency Use Only (GENERAL INFORMATION Total Conditioned Floor Area Z 5d ft- Average Ceiling Height: 8 ft Conditioned Slab Floor Area ft' Building Type: Single Family \ Addition (check one or more) Multi -Family Existing -Plus -Addition Front Orientation: North / out / East / West / All Orientations ' (input front orientation in degrees from True North and circle one) Number of Stories Number of Dwelling Units: l Floor Construction Type: Slab aised Floo (circle one or both) O C T 0 ' 2OO2 i/ RADIANT BARRIER (required in climate zones 2,4. 8-15) Required for this submittal yesno BUILDING ENVELOPE INSULATION Component Type Frame Type wd = wood stl = steel Cavity Sheathing Total R- Assembly Insulation Insulation Value] U -Factor R -Value R -Value Location/Comments (attic, garage, typical, etc.) Wall V.1 13 --- Wall Front Roof W d Left Roof t o. s- Floor �+ Floor Rear o(RT\A (1.0 Slab Edge 0. Rear ' For prescriptive compliance. Total R -Value and Assembly U -Factor are not required for a wood -framed wall that meets cavity R -value insulation requirements for the Prescriptive Packaee. FENESTRATION Shadine Devices Fenestration #/T e/Pos. Orien- tation Area (ft-) Fenestration U -Factor Fenestration Exterior Overhangs/ SHGC Shading Att. Fins Front o V T14 --- Front Left w SIT t o. s- Left Rear o(RT\A (1.0 O.7 0. Rear Right 1CO3S T Right Skylight Sky[ ht Compliance Forms August 2001 A-2 CIER'1('IDFIICA'1<'IE OF C®MIFI[.,IIAN CIE , RESIDENTIAL (Page 2 of 3) (CIF -IR V Project Title Date HVAC SYSTEMS Note: Input hydronic or combined hydronic data under Water Heating Systems, except Design Heating Load. Distribution Heating Equipment Minimum Type and Duct or Heat Pump Type (furnace, heat Efficiency Location Piping Thermostat Configuration pump, etc.) (AFUE or HSPF) (ducts, attic, etc.) R -Value Type (split or package) P—:)t�STI. N(y Cooling Equipment Minimum Duct Type (air conditioner, Efficiency Location Duct heat pump, evap. cooling) (SEER) (attic, etc.) R -Value Heat Pump Thermostat Configuration Type (split or package) SEALED DUCTS and TXVs (or Alternative Measures) Sealed Ducts (all climate zones) (Installer testing and certification and HERS rater field vcrification required) OCT ®3 292 ❑ TXVs, readily accessible (climate zones 2 and 8-15 only) (Installer testing and certification and HERS Rater or field verification required) ❑ Refrigerant Charge/Air Flow (climate zones z and 8-I5 only) (Installer testing and certification and HERS Rater or field verification required) OR ❑ Alternative to Sealed Ducts and TXVs (see Package C or D Alternative Package Features for Project Climate Zone) Climate Zone Window SHGC Window U -Factor SEER Heating WATER HEATING SYSTEMS Energy' External Rated' Tank Factor or Tank Water Heater Distribution Number Input (kW Capacity Recovery Standby' Insulation Tvpe Tyne in System or Btulhr) (gallons) Efficiencv Loss N) R -Value I. For small gas storage water heaters (rated inputs of less than or equal to 75,000 Btu/hr), electric resistance, and heat pump water heaters, list Energy Factor. For large gas storage water heaters (rated input of greater than 75,000 Bndhr), list Rated Input. Recovery Efficiency and Standby Loss. For instantaneous gas water heaters, list rated input and recovery efficiencies. SPECIAL (FEATURES (add extra sheets if necessary). Package C and D: TXVs, Sealed Ducts, Radiant Barriers (see installation requirements for radiant barriers in Section 8,13 of the 2001 Residential Manual). Package C: thermal mass (thermal mass type, covering, thickness, and description). Compliance Forms August 2001 A-3 C EILgTff FffCAT E OF COMIL" MA C Eo R ESM ENUAL (Page 3 of 3) CV -IR 71 o2. 1 -17 -OZ - Project Title Date COMPLIANCE STATEMENT This certificate of compliance lists the building features and performance specifications needed to comply with Title 24, Parts 1 and 6 of the California Code of Regulations, and the administrative regulations to implement them. This certificate has been signed by the individual with overall design responsibility. When this certificate of compliance is submitted for a single building plan to be built in multiple orientations, any shading feature that is varied is indicated in the Special Features/Remarks section. The undersigned recognize that compliance using duct sealing and TXVs requires installer testing and certification and field verification by an approved HERS rater. Designer or Owner (per Business and Professions Code) Documentation Author Name: S TEV EA A. A K N O LQ Name: Iii F—KTAP I oS i-1 A-r4ulk Title/Firm: S T Ey E A r\N)OLD Uv kL E��%�N 'fyR Title/Firm: S A Rr Address: 19 13 S T 14 F 10� 1-A 1AEDA S4� • 1110 Address: SCAY", JUSe-, C..A r1 S17 -(e Telephone: (� q) 5.S7— 9005 Lic. 4: PLS 30 /7 AB Z- ure) (date) Enforcement Agency Dame: Title: Agencv: AS UW N 1F, P, Telephone: (qOe) S57— 1005 (sienaturc) (date) Telephone: .: i f i U L' O C Y ®aid LO02 (signature; stamp) (dart) -- Compliance Forms August 2001 A-4 MANDATORY MEASURES CHECKLEST: R ESED ENTEA1L (Page 1 of 2) MIF -IR Note: Lowrise residential buildings subject to the Standards must contain these measures regardless of the compliance approach used. a Items marked with an asterisk (b) may be superseded by more stringent compliance requirements listed on the Certificate of Compliance, When this checklist is incorporated into the permit documents, the features noted shall be considered by all parties as minimum component performance specifications for the mandatory measures whether they are shown elsewhere in the documents or on this checklist only. Instructions: Check or initial applicable boxes when completed or enter N/A if not applicable. DESCRIPTION DESIGNER ENFORCEMENT Building Envelope Measures: * §150(a): Minimum R-19 ceiling insulation. § 150(b): Loose fill insulation manufacturer's labeled R-Valuc. / r' ) * § 150(c): Minimum R-13 wall insulation in wood framed walls or equivalent U -Factor in metal frame walls (does not apply to exterior mass walls). ° § 150(d): Minimum R-13 raised floor insulation in framed floors. _! § 150(1) : Slab edge insulation - water absorption rate no greater than 0.3%, water vapor transmission tate no ercaterthan 2.0perm/inch. §118: Insulation specified or installed meets insulation quality standards. Indicate type and form. § 116-17: Fenestration Products. Exterior Doors, and InSltration/Exfiltration Controls 1. Doors and windows between conditioned and unconditioned spaces designed to limit air leakage. (X` 2. Fenestration products (except field -fabricated) have label with certified U -Factor, certified Solar Hcat Gain Coefficient (SHGC), and infiltration certification. 3. Exterior doors and windows weathcrstripped; all joints and penetrations caulked and sealed. § 150(g): Vapor barriers mandatory in Climate Zones 14 and 16 only. § 150(0: Special infiltration barrier installed to comply with § 151 meets Convnission quality standards. §150(c): Installation of Fireplaces, Decorative Gas Appliances and Gas Logs. - 1. Masonry and factory -built fireplaces have: aCloseable metal or glass door OCT Q0 20oz. b. Outside air intake with damper and control �� ) c. Flue damper and control 2. No continuous burning gas pilot lights allowed. Space Conditioning, Water Heating and Plumbing System Measures: §110-§113: HVAC equipment, water heaters, showcrheads and faucets certified by the Commission. § I50(h): Heating and/or cooling loads calculated in accordance with ASHRAE, SMACNA or RCCA. §150(i): Setback thermostat on all applicable heating and/or cooling systems. § 1500): Pipe and tank insulation I. Storage gas water heaters rated with an Energy Factor less than 0.58 must be externally wrapped with insulation having an installed thermal resistance of R-12 or greater. 2. First 5 feet of pipes closest to water heater tank, non-rccirculating systems, insulated (R-4 or greater) 3. Back-up tanks for solar system, unfired storage tanks, or other indircct hot water tanks have R-12 external insulation or R- 16 combined internal/cxtcrrral insulation. 4. All buried or exposed piping insulated in recirculating sections of hot water systems. 5. Cooling system piping below 55° F insulated. 6. Piping insulated between heating source and indirect hot water tank. Compliance Forms August 2001 A-5 4 MANDATORY MEASURES CHECKLIST: R ESI DELI' IAL (Page 2 of 2) ID/IIIF-1R Note: Lowrise residential buildings subject to the Standards must contain these measures regardless of the compliance approach used. Items marked with an asterisk (°) may be superseded by more stringent compliance requirements listed on the Certificate of Compliance. When this checklist is incorporated into the permit documents, the features noted shall be considered by all parties as minimum component performance specifications for the mandatory measures whether they are shown elsewhere in the documents or on this checklist only. Instructions: Check or initial applicable boxes when completed or enter N/A if not applicable. DESCRIPTION DESIGNER ENFORCEMENT Space Conditioning, Water Heating and Plumbing System Measures: (continued) § I50(m): Ducts and Fans I. All ducts and plenums installed, sealed and insulated to meet the requirement of the 1998 CMC Sections 601, 603, 604, and Standard 6-3; ducts insulated to a minimum installed level of R4.2 or enclosed entirely in conditioned space. Openings shall be sealed with mastic, tape, aerosol sealant, or other duct -closure system that meets the applicable requirements of UL 181, UL 181A. or UL 181 B. If mastic or tape is used to seal openings greater than 1/4 inch, the combination of mastic and either mesh or tape shall be used. Building cavities shall not be used for conveying conditioned air. Joints and seams of duct systems and their components shall not be sealed with cloth back rubber adhesive duct tapes unless such tape is used in combination with mastic and drawbands. 2. Building cavities, support platforms for air handlers, and plenums defined or constructed with materials other than scaled 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. 3. Joints and scams of duct systems and their components shall not be scaled with cloth back rubber adhesive duct tapes unless such tape is used in combination with mastic and drawbands. 4. Exhaust fan systems have back draft or automatic dampers. 5. Gravity ventilating systems serving conditioned space have either automatic or readily accessible, manually operated dampers. 6. Protection of Insulation. Insulation shall be protected from damage, including that due to sunlight, moisture, equipment maintenance, and wind but not limited to the following: Insulation exposed to weather shall be suitable for outdoor service e.g., 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 OCT 02, 70OZ L uL water retardant and provides shielding from solar radiation that can cause degradation of the material. §114: Pool and Spa Heating Systems and Equipment. I. System is certified with 18% thermal efficiency, on-off switch, weatherproof operating instructions, no -" electric resistance heating and no pilot light. 2. System is installed with: a. At least 36' of pipe between filter and heater for future solar heating. b. Cover for outdoor pools or outdoor spas. 3. Pool system has directional inlets and a circulation pump time switch. § 115: Gas fired central furnaces, pool heaters, spa heaters or household cooking appliances have no continuously burning pilot light. (Exception: Non -electrical cooking appliances with pilot < 150 Btu/hr) f� § I l8 (f): Cool Roof material meet specified criteria Lighting Measures: §150(k)l.: Luminaires for general lighting in kitchens shall have lamps with an efficacy of 40 lumcns/watt or greater for general lighting in kitchens. This general lighting shall be controlled by a switch on a readily accessible lighting control panel at an entrance to the kitchen. §150(k)2.: Rooms with a shower or bathtub must have either at least one luminaire with lamps with an efficacy of 40 lumens/watt or greater switched at the entrance to the room or one of the alternatives to this requirement allowed in § I50(k)2.; and incandescent recessed ceiling fixtures are IC (insulation cover) approved. Compliance Forms August 2001 A-6 THERMAL MASS WORKSHEET ®RKSHlElET WS -IR 77-U2- -l7- G Z Project Title Date INTERIOR THERMAL. MASS: Thermal mass required for Packages C in Tables No. 1-Z1 through 1-Z16 shall meet or exceed the required interior mass capacity as specified below. Choose one of the following: Package C (Slab Floor) 2.36 X = Ground Floor Area Package C (Raised Floor) 0.18 X = Required Interior Mass Capacity Ground Floor Area Required Interior Mass Capacity Calculate the Interior Mass Capacity value using the worksheet space below. Look up the Unit Interior Mass Capacity for each interior mass surface in the Residential Manual, Table 3-12. For interior mass walls exposed on both (two) sides to conditioned space, enter the surface area of only one side. Unit Interior Interior Description Mass Area Mass Capacity Mass Capacitv X = X = X = X X X nnT X = Lu X - Total Interior Mass Cap' The total interior mass capacity must be equal to or greater than the required interior mass capacity in Irder to meet the thermal mass requirements of packages C. Total Interior Mass Capacity Required Interior Mass Capacity fiance Forms August 2001 A-7 - WATER ]H[IEATENG WORKSHEET DIHIW-1 Project Title Date No. of Different Water Heater Types: Total No. of Water Heaters: Conditioned Floor Area (CFA): ft - Notes: For single family dwellings with multiple water heaters, also submit DHW-2A. For multi -family buildings, also submit DHW-2B. Heater Type # Data A. Water Heater Type (check one) _ Storage Gas _ Large Storage Gas _ Storage Electric _ Storage Heat Pump _ Instantaneous Gas _ Instantaneous Electric Indirect Gas B. Manufacturer C. Model No. Heater Type # Data A. Water Heater Type (check one) Storage Gas _ Large Storage Gas _ Storage Electric Storage Heat Pump Instantaneous Gas Instantaneous ElecGioT 00"" ZOQ _ Indirect Gas M -' B. anufacturer C. Model No. Heater Type # Data A. Water Neater Type (check one) Storage Gas _ Large Storage Gas _ Storage Electric Storage Heat Pump In tantaneous Gas stantaneous Electric Indirect Gas Manufacturer C. Model No. D. Energy Factor D. Energy Factor D. Energy Factor E. Gallons E. Gallons E. Gallons F. Pilot Btu/hr F. Pilot Btu/hr F. Pilot Btu/hr G. Thermal Eff. G. Thermal Eff. G. Thermal Eff. H. Auxiliary Input (check one or H. Auxiliary Input (check one or H. Auxiliary Input (check one or both) both) both) _ Wood Stove Solar 1. ®istribution System (check one) Standard Hot Water Recovery (HWR) _ Point of Use (POU) _ Pipe Insulation (PI) Parallel Piping (PP) Recirculation: No Control Recirculation: Timer Recirculation: Temp. Recirculation: Time/Temp. Recirculation: Demand HWR+ Recirculation: Demand PI + Recirculation: Demand ]Energy Use Calculation la. Standard Recovery Load (from Table 6-5, DHW-2A or 2B) Ib. Distribution Credit/Penalty (from Table 6-6 or 6-7) 1 c. Solar Fraction (from Table 6-9) 1d.Solar Energy Credit (Ic x la) 1 e. Adjusted Recovery Load (Ia- lb- Id) 2a. Basic Energy Use (from Table 6-8, DHW-2B or 3) 2b. Wood Stove Boiler Credit Factor (from Table 6-10) 2c. Wood Stove Boiler Credit (2a x 2b) 2d. Proposed Energy Use (2a - 2c) 3. Standard Energy Use (from Table 6-5) �J Wood Stove Solar I. Distribution System (check one) _ Standard Hot Water Recovery (HWR) _ Point of Use (POU) Pipe Insulation (PI) _ Parallel Piping (PP) _ Recirculation: No Control _ Recirculation: Timer Recirculation: Temp. Recirculation: Time/Temp. _ Recirculation: Demand _ HWR + Recirculation: Demand PI + Recirculation: Demand Energy Use Calculation Ia. Standard Recovery Load (from Table 6-5, DHW-2A or 213) 1 b. Distribution Credit/Penalty (from Table 6-6 or 6-7) lc. Solar Fraction (from Table 6-9) ld. Solar Energy Credit (Icx la) 1 e. Adjusted Recovery Load (la- lb- Id) 2a. Basic Energy Use (from Table 6-8, DHW-213 or 3) 2b. Wood Stove Boiler Credit Factor (from Table 6-10) 2c. Wood Stove Boiler Credit (2a x 2b) 2d. Proposed Energy Use (2a -2c) 3. Standard Energy Use (from Table 6-5) _ Wood Stove Solar 1. Distribution System (check one) _ Standard Hot Water Recovery (-H—WR) _ Point of Use (POU) Pipe Insulation (PI) _ Parallel Piping (PP) _ Recirculation: No Control _ Recirculation: Timer _ Recirculation: Temp. _ Recirculation: Time/Temp. _ Recirculation: Demand _ HWR + Recirculation: Demand PI + Recirculation: Demand Energy Use Calculation Ia. Standard Recovery Load (from Table 6-5, DHW-2A or 2B) lb. Distribution Credit/Penalty (from Table 6-6 or 6-7) Ic. Solar Fraction (from Table 6-9) 1 d. Solar Energy Credit (lc x la) Ie.Adjusted Recovery Load (la- lb- Id) 2a. Basic Energy Use (from Table 6-8, DHW-2B or 3) 2b. Wood Stove Boiler Credit Factor(from Table 6- 10) 2c. Wood Stove Boiler Credit (2a x 2b) 2d. Proposed Energy Use (2a - 2c) 3. Standard Energy Use (from Table 6-5) 4. For Prescriptive Compliance (one water heater per dwelling): Line 2d must not exceed Line 3 Compliance Forms August 2001 A-8 . . SNNGILIE IFAMRLR W/ MULLTEPLLIE WATER HEATERS 161�� ���� •� d Project Title Date Note: In addition to this form, a DHW-1 Water Heating Worksheet must also be submitted to document water heater type(s). Single Family Project Data I. No. of different water heater types: OCT 99 Z9�z 2. Total conditioned floor area: fr No. of Heater Heaters Type # Manufacturer & Model No. 3a. # 1 3b. 3c. 4. #2 #3 Total Number of Water Heaters 5. Standard Recovery Load: 6. Recovery Load Per Heater: 7. Proposed Energy Use, Heater #1: 8. Proposed Energy Use, Heater N2: 9. Proposed Energy Use, Heater #3: 10. Total Proposed Energy Use: 11. Standard Energy Use: Compliance from Table 6-5 based on line 2 (line 5 _ line 4); enter on DHW-1, line 1a for each Heater Type, and complete calculation through line 2d. (from DHW-1 Iine 2d, Heater #1) x (line 3a) (from DHW-1 line 2d, Heater #2) x (line 3b) (from DHW-1 line 2d, Heater #3) x (line 3c) (line 7 + line 8 + line 9) from Table 6-5 based on line 2 12. Prescriptive Compliance: Line 10 must be equal to or less than line 11. See Section 6.1 and Chapter 3 in the Residential Manual for details. Compliance Forms August 2001 A-9 - WATER HEATING FOR MULTI -FAMILY BUI LMNGS DHW-2B a rroject t me Date Notes: In addition to this form, a DHW-I Water Heating Worksheet must also be submitted to document water heating type(s). If the calculation (line 5) is by "Individual Dwelling Unit" and system configuration (line 6) is "Individual Heaters," no additional information need be entered on this sheet. Multi -Family Project Data I . Number of dwelling units: 2. Total conditioned floor area: 3. Average floor area: 4. Standard Recovery Load: 5. Calculation by (check one): 6. System configuration (check one): ft' OCT 0 '9") 20�� (Line 2/1-ine 1) (from Table 6-5 based on Line 3, enter on the 1 a) Average Dwelling Unit Individual Dwelling Unit Individual Heaters (one per dwelling unit) Shared Heaters (multiple dwelling units per heater) Analysis by Average Dwelling Unit One Individual Heater Per Dwelling Unit No. of Heater Gallons Ener Factor Thermal Efticiencv Heaters Type# Manufacturer and Model# Each Total Each Total Each Total 7a = 7b = 7c = 8a = 8b = 8c = 8d = Total Total Total Total 9a = 9b = 9c = Ave. (8b/8a) Ave. (8c/8a) Ave. (8d/8a) Individual Heaters I Oa. Enter value 9a on DHW-1 Line E. I la. Enter value 9b on DHW-1 Line D. 12a Enter value 9c on DHW-1 Line G. 13a. Check compliance on DHW-I for average dwelling unit and average water heating, Shared Heater(s) I Ob. Average unit Adjusted Recovery Load: 1 lb. Total Adjusted Recovery Load:-' 12b. Total Basic Energy Use: 13b. Average Unit Basic Energy Use: 14b. Check average unit compliance on DHW-l. From DHW-1, Line le (Line 1) x (Line IOb) From Table 6-8, or DHW-3 (Line 12b) _ (Line l): enter on Line 2a, DHW-1 Compliance 15. Prescriptive Compliance (for individual or shared heaters): DHW-1 Line 2d must be equal to or less than DHW-1 Line 3. See Section 6.1 and Chapter 3 in the Residential Manual for details. Total Gallons = (No. of Heaters) x (Gallons for each heater of this Heater Number) Total Energy Factor = (No. of Heaters) x (Energy Factor for each heater of this Heater Number) 3 Total Thermal Efficiency = (No. of Heaters) x (Thermal Efficiency for each heater of this Heater Number) 4 For a Large Storage Gas Heater proceed to DHW-3, no additional information need be entered on this sheet Compliance Forms August 2001 A-10 IINDMIEcCT & LARGE S IFO AGIE GAS WATER HEATERS DHW-3 Project Title Date Note: This sheet must also be submitted with a DHW-1 water heating worksheet, as well as a DHW-2B form with large storage gas heaters in multi -family buildings. Indirect Gas Water Heaters 1. Storage tank Manufacturer/Model No. OCT 0 2002 2. Boiler and Instantaneous Heater Manufacturer/Model No. - - 3. Storage tank insulation R -value: Tank External tall =- 4. Storage tank volume (gallons) 5. Boiler AFUE or Instantaneous Water Heater Thermal (Recovery) Efficiency EFF = 6. Adjusted Recovery Load (MBtu/yr, from Line le, DHW-1) ARL = 7. Jacket loss (MBtu/yr, from Table 6-8E) JL = 8. Pilot Energy (Btuh, from appliance database, or use 800) PE = 9. Basic Energy Use: BEU = AR' + A + (PE x 0.00876) BEU = 0.98 x EFF (Enter BEU on DHW-1, Line 2a for single family or on DHW-2B, Line 12b for multi -family) ]Large Storage Gas Heater' (> 75,000 Btuh input) 1. Water Heater Manufacturer 2. Water Heater Model No. 3. Storage Tank Volume (gallons) VOL = 4. Water Heater Thermal (Recovery) Efficiency (decimal fraction) EFF = 5. Adjusted Recovery Load (Mbtuiyr) (From Line t e, DHW-1 for single family or Line 11 b, DHW-2B for multi -family) ARL = 6. Standby Loss % (from appliance database - e.g., "2.7") SBL% = ARL (5.461 x SBL x VOL) 7. Basic Energy Use: BEU = + BEU = EFF 100 (Enter BEU on DHW-1, Line 2a for single family or on DHW-2B, Line 12b for multi -family) ' The Domestic Hot Water Heating forms (DHW series) restrict the user to only one Large Storage Gas Heater per permitted space. In order to use more than one Large Storage Gas Heater the computer peformance method must be used. Compliance Forms August 2001 A-11 Solar Heat Gain (Coefficient (Sa-GC) Worksheet Page I of 2 ]FORM S Items I through 4 must be completed for glazing/shading combinations by using the Default Table for Fenestration Products (Table S-1) ; NFRC certified data, or Solar Heat Gain Coefficients Used for Exterior Shading Attachments (Table S-2) for the specific conditions indicated (41a or 91b or #3). For instructions on filling out the worksheet, see Shading in the RM Glossary, Appendir G. General Information Ia. For Fenestration Products w/NFRC testing and labels: SHGC,,,,_ OR lb. For Fenestration Products without NFRC testing and labels (Table S-1):SHGCj�.„ = lc. Frame Type Id. Product Type le. Glazing Type If. Single/Double Pane metal, non-metal, operable/fixed (visibly) tinted single pane/double pane metal w/thermal break clear (not visibly tinted) 1. 2. Skylight (YACT 0 2002 ("Skylights" are glazing having a slope of less than 60 degrees from the horizontal with conditioned s e below) Combined Exterior Shade with Fenestration Exterior Shade Type: 3. SHGCEveriorShade: V (If no exterior shade, assume standard bug screens, SHGCEx1eri0rSi,„,je = 0.76 for ordinary windows. This requirement does not apply to skylights where SHGCE.vw,i,,,S1 de is assumed to be 1.00. If another exterior shade is substituted for bug screens, use one of the values from Table S-2 Where: 4. [( x 0.2875) + 0.751 x = SHGC= Larger of (#1 a or #1 b) or #3 SHGC, SHGC;,, Total SHGC = Smaller of (#la or #lb) or #3 Note: Calculated Solar Heat Gain Coefficient values for Total SHGC may be used directly for prescriptive packages. Target Value for Total SHGC is 0.39 for Package Requirement of SHGC/�„ = 0.40. TABLES TableS-1: DEFAULT FENESTRATION SOLAR HEAT GAIN COEFFICIENT Total Window SHGC Single Double Frame Type Product Glazing Pane Pane Metal Operable Clear 0.80 0.70 Metal Fixed Clear 0.83 0.73 Metal Operable Tinted 0.67 0.59 Metal Fixed Tinted 0.68 0.60 Metal, Thermal Break Operable Clear 0.72 0.63 Metal, Thermal Break Fixed Clear 0.78 0.69 Metal, Thermal Break Operable Tinted 0.60 0.53 Metal, Thermal Break Fixed Tinted 0.65 0.57 Non -Metal Operable Clear 0.74 0.65 Non -Metal Fixed Clear 0.76 0.67 Non -Metal Operable Tinted 0.60 0.53 Non -Metal Fixed Tinted 0.63 0.55 SHGC = Solar Heat Gain Coefficient Compliance Forms August 2001 A-14 &� 0, Mar Heat Gain ®ef�neun>t (SIH[GC) ®>rl�s➢>iee>t Page 2 of 2 FORM S TABLES (Continued) Table S-2: Solar Heat Gain Coefficients Used for Exterior Shading Attachments for Form S and Computer Performance Methods 1.2 Exterior Shading Device w/Single Pane Clear Glass & Metal Framing' 1) Standard Bug Screens 0.76 2) Exterior Sunscreens with weave 53* 16/inch 0.30 3) Louvered Sunscreens w/louvers as wide as openings 0.27 4) Low Sun Angle (LSA) Louvered Sunscreens 0.13 5) Roll -down Awning 0.13 6) Roll Down Blinds or Slats 0:13 7) None (for skylights only) 1.OoC� ©� c� Z002 `. 1. These values may be used on line 3 of the Solar Heat Gain Coefficient (SHGC) Worksheet (Forn to c elate exterior shading with other glazing types and combined interior and exterior shading with glazing. 2. Exterior operable awnings (canvas, plastic or metal), except those that roll vertically down and cVv r the entire window, should be treated as overhangs for purposes of compliance with the Standards. 3. Standard bug screens must be assumed for all fenestration unless replaced by other exterior shading attachments. The solar heat gain coefficient listed for bug screens is an area -weighted value that assumes that the screens are only on operable windows. The solar heat gain coefficient of any other exterior shade screens applied only to some window areas must be area -weighted with the solar heat gain coefficient of standard bug screens for all other glazing (see Weighted Averaging in the Glossary). Different shading conditions may also be modeled explicitly in the computer performance method. 4. Reference glass for determining solar heat gain coefficients is 1/8 inch double strength (DSS) glass. Compliance Forms August 2001 A-15 CERTIFICATE OF FIELID VERIFICATION AND Pi.?AGNOSTIC TESTING (Page 1 of 7) CF -4R Project Title Project Address Builder Contact HERS Rater Certifying Signature Firm: Date Builder Name Telephone Plan Number Telephone Sample Group Number Date Sample House Number HERS Provider: Street Address: City/State/Zip: Copies to: Builder, HERS Provider CCT HERS RATER COMPLIANCE STATEMENT The house was: ❑ Tested ❑ Approved as part of sample testing, -b t as not ted As the HERS rater providing diagnostic testing and field verification, I certify th e houses identified on this form comply with the diagnostic tested compliance requirements as checked on this form. ❑ The installer has provided a copy of CF -6R (Installation Certificate. ❑ Distribution system is fully ducted (i.e., does not use building cavities as plenums or platform returns in lieu of ducts) ❑ Where cloth backed, rubber adhesive duct tape is installed, mastic and drawbands are used in combination with cloth backed, rubber adhesive duct tape to seal leaks at duct connections. ❑ MINIMUM REQUIREMENTS FOR DUCT LEAKAGE REDUCTION COMPLIANCE CREDIT Duct Diagnostic Leakage Testing Results (Maximum 6% Duct Leakage) Measured Duct Pressurization Test Results (CFM @ 25 Pa) values Test Leakage Flow in CFM If fan clow is calculated as 400cfm/ton x number of tons enter calculated value here If fan flow is measured enter measured value here Leakage Percentaec ( 100 x Test Leakage/Fan Flow) = Check Box for Pass or Fail (Pass=6% or less) ❑ ❑ Pass Fail ❑ THERMOSTATIC EXPANSION VALVE (TX ❑ Yes ❑ No Thermostatic Expansion Valve is installed and Access is provided for inspection ❑ ❑ Yes is a pass Pass Fail ❑ MINiMUNI REQUIREMENTS FOR DUCT DESIGN COMPLIANCE CREDIT 1 • ❑ Yes ❑ No ACCA Manual D Design requirements have been met (rater has verified that actual installation matches values in CF -IR and design on plan. 2. ❑ Yes ❑ No TXV is installed or Fan flow has been verified. If no TXV, verified fan flow matches design from CF- l R. Measured Fan Flu;: _ ❑ ❑ Yes for both I and 2 is a Pass Pass Fail Compliance Forms August 2001 A-16 4b CERTIIFICA "E OF FIELD VERIFICATION ANIS DIAGNOSTIC TESTING +,Page 2 of 7) CF'4R or Site Address Permit Number ❑ REFRIGERANT CHARGE ANIS AIRFLOW MEASUREMENT Verification for Required Refrigerant Charge and Adequate Airflow for Split System Space Cooling Systems without Thermostatic Expansion Valves Outdoor Unit Serial # Location Outdoor Unit Make Outdoor Unit Model Cooling Capacity Btu/hr Date of Verification Date of Refrigerant Gauge Calibration (must be checked monthly) Date of Thermocouple Calibration (must be checked monthly) Standard Chame and Airflow Measurement (outdoor air dry-bulb 55 OF and above): , ; I Note: The system should be installed and charged in accordance with the manufacturer's specifications and installer verification shall be documented on CF -6R before starting this procedure. If outdoor air dry-bulb rs,(e�o 5 ° g shall( return to verify charge and airflow at a time when temperature is 55 OF or greater. ( l6 I ❑ Yes ❑ No A copy of CF -6R (Installation Certificate) has been provided with refrigerant ch e and . w measurement documented. Measured Temperatures Supply (evaporator leaving) air dry-bulb temperature (Tsupply, db) OF Return (evaporator entering) air dry-bulb temperature (Tretum, db) OF Return (evaporator entering) air wet -bulb temperature (Tretum, wb) OF Evaporator saturation temperature (Tevaporator, sat) OF Suction line temperature (Tsuction, db) OF Condenser (entering) air dry-bulb temperature (Tcondenser, db) OF Superheat Charge Method Calculations for Refrigerant Charge Actual Superheat = Tsuction, db — Tevaporator, sat OF Target Superheat (from Table 1) OF Actual Superheat — Target Superheat OF (System passes if between -5 and +5°F) Temperature Split Method Calculations for Adequate Airflow Actual Temperature Split = T return, db - Tsupply, db OF Target Temperature Split (from Table 2) OF Actual Temperature Split - Target Temperature Split OF (System passes if between -3°F and +3°F or, upon remeasurement, if between -3°F and -25°F) Standard Charge and Airflow Measurement Summary: System shall pass both refrigerant charge and adequate airflow calculation criteria from the same measurements. If corrective actions were taken, both criteria must be remeasured and recalculated System Passes yes or no Compliance Forms August 2001 A-17