S 2605 (2) --APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-EFECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 2605 BUILDING PROJECT IDF.NfflOC
flc 67 5
RUH.DING ADDRESS: U N14r SANI TARY NO, APPLICN'ION SOI{MI'ITAL DAPI
234%,071 ,P Lkbfi: . 0A-K. lees, �s— i r v a)-6 �1-2 6 -49
OWNERISNA El) 6 A PHONI?: CON'FRACIORS NAf IA I.ICNO'.
ARCH]T' / NEER: LIC NO: ADDRESS: ❑ 7 22 9
)NTACB PHONE. , BUILDING PERMIT INFO
❑ Cnnsullaat Fees Paid by Applicant(Initial) BLDO ELECT PLUMB MECH
LICENSED NSED NTRACTORS Df CI ARA'I']ON QTY ELECTRIC PERMIT
I hereby Hint I licensed provisions of Chapter91 nme 'ng - JOB DESCRIPTION
O�Z InhSecom"700C)"I'Doo 3 fit lits 1 d �y ylice :m I_ S ) T7 I:
+�I00 PERM]I'ISSUANCE 3V'.��
w.. in1u11ltw,m etre.,. WL 0 KI'HCHEN REMODEL
¢UU Licensc Lich APPLIANCHS-RESIDENTIAL El ADDITION El PLUMBING RE-PIPH
m�i Umc Tl"Isn"no
RCHrrrcrs :.0 , ❑nro1.TI-urlrl' ❑s'rauc'ruenl.
'Mon 1'ANEI G
Z O�'z I unJorswnJ mY Pln,u shell he used ux public rn:nrdn NIODIFCIEMN Y REPAIR OZ� UI'T02g1AMl'S ❑1N'IJ3RIQR ❑CHIMNEY ItEI'AIR
tw Licensed Prot....anal 201-IOMAMPS IMPROVEMENT C]SWIMMING POOLS
OWNER-BUILDER DECLARATION
C m I hereby a1'Iirm Thal I am exan:p,fro...16c Conuamar's IJ.en,'c Law far the OVER 1000 AMPS 0 BATH REMODEUREPAIR 0 DEMOLU)ON
X11 O y U fallowing mann.(Station 91131.5,lamems and Professions Code:Any cily ar rota y SIGNS ELECTRICAL 0OI TIER
FW O�' which rr9airet u permh a.....teat alma l,nprave.Ac,nnlish,nr repwr uny.wemm
N priorto itsis I the pplc t forsuchpe f to File a signed'„ement SPECIAL CIRCUIT/MISC.
2 }�,
that he licensed pt atme ponisions ofibumContractors License I' ((1 ptcrit
W �p (cn...rem tg wlh SOciun700)IfUvstn3cflbe Business and Professions Cam le) HEMP.METER OR PULP INST. COMMERCIAL'
d a c C [flat he is exempt Ilicrefom and the basis for the alleged exemption.Any vlalation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 9031.5 by uny oppli,ml for.panni,s,,bjeaa the np ifcam m a civil proulO of POWER DEVICES
B1�w OTfiNAN'1' ❑FOODSERVICE
>ynet morethan Fred hundred dollars($510).
Wip IMPROVEMENT'0i,nsownar afore pn:peiny,,nn,employee'with w.gas as mcirsdle cmr,mu,ian, SWIMMING POOL ELECTRIC
^m will do the work.and the structure is out intended molTeddl lin sale Sed.7(44.Business [I OL IF.R
W and Professions Code:'rhe Comra,oa,License Law doer not apply In en owner of OUTLETS-SWITCHES-FIXTURES
63 properly who builds or improves thereon,and who dues such work himself or through
his.,it employees,provided that steel,ilop ovese.s arc no,intended or of@red for NEW RESIDENTIAL ELE(MR SQ FT
sale.If howcG,,,Ihebmidiri,minipmmhln
vccnt issoldwitaneycarof ,hc compicasomy �2 SQ.Ff.II,OOIt AItGA $ISQ,fT.
er-builder will havc the huN.n l prow.....f he did no,built or impnwc for per-
oxisealsule.).
,o Las or Mm
wneme PpenY,ata excWnivuly e....:mcting win,I'mcnseA nmumuars m ''OTA
construct the projdc,(See J(W,Rasmesand Profession.,Cede:)The Commerce,Li- -ccow or trip r..r,the,Ono,and QTY, PlA NG FERMIF FEE,
who contracts for such p Jects with a cantmcmrp)licensed pursuant to the Contractors
License Law. ]GAS
T ISSUANCE
0 1 nT rs,duE under Sec. .R&P C fnnM1i'nson
Owner Dwc -DRAIN&Vice .k LEA) VALUATION
WORKER'S COMPENSATION DECLARAT,ON FLOW PROTIiCE DEVIL 2000,
I hrshy alfrnn under stalky of Pegryry anal and following dedamtinn
%ok
24
1hiocrolwill maint.m.Certificate ofConanl la self insus for W-1hol,Compen- S-FLOOR.ROOF ARCA.CO SFOIt1ES '1'YPH CONSTRUCIION
on.aspoMdrd fdf by Section 391x1of the LaborCore,1'orthe periamsmce of me
Ibr%hieb,his panni,is issued. RES-PER TRAP
❑1 have and will maintain Wd,Jsds Contpensatitn Insmmnce,ter na ired by Section
3700ofmc labor Code.for meperfonnancc n[the work forwhich this pemtit is issued, HA.SYSTEM-I INC.4 OUTLETS ,JCC GROUT' MIN
My Worker's Compen.,ion Inwnnuc,arrlcr and Pn11cy number arc:
Cartier. Policy No.: F.A.SYSTEM-OVER 4(HA)
CERTINCATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFANDUSTRI.WASTE INTF.RCEPI OR IhJUILolNO DIVISION FEES
(This section need nal becnmpleed if the pooni,is foronelmndred dol I.,(S l off CREASE'1'RAI'
less.) PLANCHE HE 2--1 s /Q
Icenify that in performance of the work for which this petitionisisweglshall SEWER-SAN ITARY_Sr I OHM EA.200 IT.
not employ any Iter,on i n any manner so as m become subject to the Workcty'Goo,mry 13NERG NE 2 20
zz sationl.zweaf Califdmia.Date WATIiR IiIiATIiR WNHN'I91iL[CI'R
Q Applicant GRA I FF.
.N. NOI'ICE'10 APPLICAMr:If,afmr..kid,this Certificate of Exemption,you should WATI7R SYSTEMn'RFATING SOILS P
Oceanid subject to'he Workers Cang do-flon Pm sio Is of the L.Aso Cudr,yoon ,.,x,
Lkl forthwith comply with mch provisionsnr this permashall be daned,evoked. WATER SERVICE
li Q
CONSTRUCH091.IiionlNGAGENCy' NEW RESIDENTIAL PLMB. SQ.PT. PAID nm Receipt
zK
�
U
1 hereby nffimt the there Is a nmstruutlOn lending agency for the perlinmance of U
the week for which Chir panni,is ixmmd(Sec.309"/.Civ.C.) -
I•' Iacrals sNemc TOTAL'
C.) Lndar'x Address TO'1'A
Ol
le,railledI ve read,hisapplic.ion:rod fmle,hnl mendwcinfisrmutidn in BUILDING FIR
"at", ,agree to uaoply will,ell any andcdnay noflnancd'and side laws rclnting to QT NICD ;1[--R FEE
U ,'� building nmslmclion,ant hcrcby aumnrize reprcsemmives of lhiscity ntemer urymthe SIiI$M1G IT.
ulwvwnentionul IF I,for impaction pnep..11, PERMI'BISSU NCH P7-1
(We)agree to sure,indemnify and keep M1annless the City of Curyoia.againststs
^iablfilies,judgmens,coslsnnd expenses which,nny in uny way uccnm ogninet x:,iA City ALI'11R Olt AU1)TIM�1(Din nxeyncnce ofthegraming ofthis pemtit. a PLUMBINGAPPLICANT )NDIiRS'I'ANDS AND WILL COMPLY WITH ALI NON-POINT AIR I IANDLING UNEP I'I'01B(DOCMIiCHANl'SOIna ILATf`SD , / _`J�/`YIe� A GUNIT(OVIIIt IOIM 1 ;PM) CONS'TRUC TAXSIg rare pplicanVCnntmc U EXHAUS'1'1100D HOUSING stiff 11A'I'ION PEE
HAZARDOUS MATERIALS DISCLOSURE
Will am.ppliea.or fururc building ove.pam sees ar handle ha...dom on lienal I IHA'I'ING ON rip if G 1Odfun RTU)
nr drEmd by the Ca"t-tind Municipal Cuda Cle"or,9.12,.nd,he Ue.lth and Safely
Ctdc,Section 25532(1 I HEAHNC ONI'ILOVER 100,110 111 U)
❑Yds ,glllf+kty. PAID
VHN'I ILA'I'ION PAN fSINOLB RP,FID) Date R...ip,M
Will me uppl leant or future hnllding......art nee nluipn,m I.devices which
kmrdom air contarboanu as defined by the Buy Arca Air Quality Management ROILI:R-COMP(3HP OR I0k010 It I'U)
UTAI.:
let? 13011.Hk-COMP(OV BR Ido J00 R'lD
❑Yes l Nd
I have read the hazarddro materials' o under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
qui' p
famia He,th&Safety Calc 8
Sections 25505. 533 and 25534.1 undersmnd,hm If the NEW RESIDIIN'1'IAL MECU SQ,
buildin nal currently haven munL,hul i,i,my rc'{wn>:biliry,o nn ythes cup., �� �6 ( P
x
of lhr ertytrt cl poor lu inmtnnm of.Ccililc trJ
Owt neat.gen Lam TOEkI ISSUED IIY:
OFFICE
Brian Kangas bulk
Engineers a 9arveym . Planners
i
Mav 27, 1999
960069.70
Chuck Schoenberger
O'Brien Group
2001 Winward Way,Suite 200
San Mateo,CA 94404
Subject; OakValley—Foundation VoriOeation
Dear Chuck,
On May 26, 1999 we performed a fi(:;d.survey blithe location of the foundation forms for the b0ldin;s
being constructed on Lot 5-32; Lot 5-35 end! Lot 5.39 of the Oak Valley prgiect in Cupertino.
The results of that survey clearly shcw that the location of:he foundation rams are consistent and in
confotmanee with die design locatioa of die buildings,as said locations are shown on die plans prepared by
our rirm.
This letter Is Intended to provide ybL with the verification orthose units per our survey. If there are any
other questions concerning chat loexion,please do not hesitate to call
Sincerely,
S6
9
BRIAN I<ANGA$ FOULK
CR6A:ES R.CIAA01
Charles R. Ciardi P.L,S.7321
Project Manager u) Nu.7321 ,
Survey Department flf CAt 1'y`sQ.
r
540 Price Avenge . Redwead City.CA 94063 • 16501462.5300 . PAX(550)4624399
14AJZZA
DATE JOB NO,
Consulting Engineers and Scientists r -`i5
425 ROLAND WAY PROJECT
OAKLAND, CA 94621 �� llr Y\'- ?.�"Ii,�
(510) 568-4001 OCATION
TO Ci 1 j!-i r.1 I/GT CONTRACTOR OWNER
Date / /�' -��{ ~, !CC 1 Yt" WEATHER TEMP. 7P *at AM
Cl:inr <- at PM
Hours Charged To Project ^ Nuclear Density Tests Qi PRESENT AT SITE
• Field Task Number r`•` F Concrete Cylinders /r
THE FOLLOWING WAS NOTED:
re G:� I'P(7t. --�, i-Cr t�'-r
���,-. 3l- ! 5�3 � C;�,�[7 % ' �`! �Lr-�� T v. �,,., �- CrJF.r ��_, .-r �.; , (- >(a�:•i 5
I
,— QI'(' (.c"�:; 1 '�.C`I rG;- (SII ���'1'"('.-C �Z« i � `)I-PP � il;i�,'l c4f"ivv1S /?n
Ln =, i '1i-U rCl9
6 1/ Ti-!, .Ce r,
G.: i[% c,:=P(C. F • lC ril' w'! I:_i,^i ni^ 1&05C i')7p I'CriGI r/1 `_.'I{i � Q...:pl
r('{ C ).: F .- v1. G n. J,'C•. . ><. i >
i
�- � /,h".C,.l�l r I , :'ct � Y�C i'.(T).T i v>�Ly :��;>,� r'. !� ;.,1 � , �;r,.l l( L'�r � 1 rFl• —rY_7
COPIES TO
SIGNED �r /(•,--`. �zi�
!R.-.R1 NO.Q36 P.Z/Z
Brian Kangas foulk
Engineers . Surveyors • Planners
•
May 27, 1999
960069.50
Chuck Schoenberger
O'Brien Group
2001 Winward Way,Suite 200
San Mateo,CA 94404
Subjeett OakValley—Foundation Verification
Dear Chuck,
On May 26, 1999 we performed a field survey of the location of the foundation forms forthe buildings
being constructed on Lot 5-32,Lot 5-35 acid Lot 5.39 of the Oak Valley prcleel in Cupertino.
The results of that survey clearly shcw that the location of the foundation forms are consistent and in
conformance with the design locatioa ofdte buildings,as said locations are shown on die plans prepared by
our firm.
This letter Is intended to prov;de yet with the veriticadon of those units per our survey. Ifthere are any
other questions ceneeming that loca.ion,p!ease'do not hesitaic to call.
Sincerely,
5rr0 G?b
• k' C// r dam,
BRIAN KANGAS FOULK
CHAR,ES R.CIARDI 'e
Charlas R.Ciardi P.L.S.7321 4` ESP.9,130/0) 'A
Project Manager u') No.1321 �?
Survey Department ArF fJf I,hl i�o�`
840 Price Avenue . Redwaad Clry.CA Sall 1650)462-5300 . FAX 1640)462.6399
•
r
�• ENGINEERING WEST INC.
OBSERVATION CHART
OAK VA.LEY DEVELOPMENT CUPERTWO. CA. PAGE 2 OF 3
1.24.2000
Lot ian ONTIOIJ dn, etboor—' oho I rEXI ,ljl Sec. fr. nl aaic 9/m
5 1 3E 3 (, Q No 0411419 7/27/99 07Q /99
BMR 09121/.9 N/A
5 3 0MR (19 1/99 NIA 10/01N0
• 5 4 4C 2 ('4.29.99 07/01199 09/24/98 10/01/99 10!1118
6A NUS 4 -- /1 199D9R2 99— 0982/99
'A 3 11) 4.29.99 05/14199 OBR /9A 0980199 0
5 7 5C 2/1 US 2)04.29.99 06!11199 09/15/99 09115/99 101Q1R9
8 3 1419199 11 1 9 9/01 9 09108/99 0 R8
5 9 30 2 - (14119/99 05107199 09103/98 C9/03/99 09(J 1,99
5 10 68 2/F70NU5 (14119199 0588199 09103/99 09/03/96 098CA9
5 it C 3 042 •B9 05 i15A /98 8 018 09/15/99
5 12 60 3/50 US 04101/99 0581!99 0883/99 _0683199 09103/99
5 13 3C 3/BONUS 04/01 89 627/89 06/18/ 9 '_C8/13!99
5 14 6E 2/F ONUS 04701/98 07102199 08/16199 0B/181E9_ 0 111
08 3/99
5 15 3A ON 'S 04/01189 05/17199 09/10/99 08112199
,C V/// 1 . J. 9.
S 17 4A 1102199 1223 99
5 15 50 '111 199 12.15•D9
5 18 5C ' 1l /9 1 •13.99 1- 0-200
5 0 3C "1/02/9 1210 198
21 58 0 /18 9 10114
ce,18/90 oW7199 1-z1• oo ••"1.20n .n. .
s z3 1c oenero9 o9n719A 1•zo•2oo0 +-2la000 d.n.a
5 4 A 2 0 �3/ 9 10.4-W 1.182000 d.n,a.
5 25
5 26 — 011 B
5 27 t6 2 1199 I B 10/041 101114199 1 /14 9
5 28 7B 2 05,07199 0889199 1 10/07/99 10114/98 1011429 1
5 29 1D 2 05-10.99 /09199 10/18/88 10/16/08
5 30 MR
5 3/ BMR
5 32 4A 3 1 /99 D7 W99 10.22.99 -r 10.21`-9 0 77DD
5 33 2A 3 05/07199 071112%99 11/09/9 1-9 99
5 34 3B 2 US/07199 07(23199 11/08/99 12.1.99 12.1.99
5 35 5 3,90NU5 )58899 0'126/ 9 1t-10.99 11.10.89 1Z•b-BB
536 12.9.99
5 37 Q 2 3/99 0726199_ 11._12_90 11.22.99 1 14
5 36 3E 2 )583/99 OB112/99 1 •22.99 1 •2.99 121
9 6A 726A3/09 119/18/99 12.6.99 12.8.99 12.11.99
5 40 0C '!BONUS ) 1 9 6/12199 12.13.98_ 12.1399 __•
41 3A ) IOB,Ki9 0883/99 t-3.202 _ 1.3.200
•(1)LOT 6 PLAN 2A✓1 LOl 7 PLAN 5C
DID NOT OBSERVE PIERS
•(2108L SIDED SHEAR WALLS
(3)FLR.NAILING
•
EN�INFEF?IPJG WF-ST INC.
WARZA C 0
.. DATE JOB NO.
Consulting Engineers and Scientists 5-- .27 -x-
425 ROLAND WAY PROJECT
OAKLAND, CA 94621
' (510) 568.4001
- r7 b
TO •') "i-,r r t ! 'e .f ) ao OWNER
Data 7' ?� � �i q /�l.l.l r 5do l WEATHER TEMP. w °at AM
J Cler[. :r-'at PM
Hours Charged To Project Nuclear Density Testa PRESENT AT 617E
� r I ,
Field Task Number T`f[ i Concrete Cylinders (/:L
THE FOLLOWING WAS NOTED:
IC [)w rI°ll[le- Irrll " r r11� �r rl -� •� it lint r rF
a
'< -4,7 (S6) rr 35 �G[ t� r I- 61 )" V ! r I— Slel , 15
li [ t[' I[ `.1-rrl 1vtjd e4r bI ` re 1r(
lre,,k eI , :, hu rr, -i . t: e
'Pl
n ,I r4 L I )'I'C F' rr -F a, "w; r'- IGC'5P I') rIC. 1 r//' OI-frI CL-, 'e-1
_ I. • tomI'% % ,w, Crlr , rdTc 1
W.
1 t f( ' ( cv-e-/r[ 1 1 1 p (Ll {-I') r, I , � `)PI-
t'-' ''lr , �r('l 'TCJ
r
I
w (
COPIES TO ' 1
SIGNED
.r.J. PdE i \
GROJPr
,r
' tl
k 1-4
^0 I
JiM.Riploy(SMTP Hploydg(gpocbell nolo
s, Monday, March 08, 1899 2 28-AM i
PAT BURKE "r
I r }s a �OAK lVALL EY,110R7A1d' "� ' h"1` 1 vllr?4f [f, o`i) 91xr� r rr p Mit ` t'pllfR t'^ruC)'� {lry+„�(, ltfjrl i ,
t6ki',('ii�!I y
ju, :01v-N A t.i.(:1 'r aU � r Sial^
ke11!^1F5
flay ,
.-
ca Linear parkway planling . : _ i
LYi:rtitit� �y�}r t. e j 1R M
,, .. , t;. ➢ t ♦, �t i li 'r 'x ; i 4.
ngs wllhIn Iha Ilnaer
Park are,00nslslonl wlIh' Iho londscapo .' q
11on 98o> d ec prepared by This of lce`and,roVIewed by the city IVIt ?
h 1riconform,wllh
Iha rolimwin,e ryop �proyall doumenls,�
p
m
Rlpley�Ffi� R}t ff.rr$�ty,ts x»�1>rlJ`� ''.��vrlJ 'I r ... . Ytix.lw.r n>sX11 {rG ). J .•wpe� { a rli�.
esign Group, Inc , d f
":1rr
>C-);� 1''N�1f1.r '(.Pd ,�d ni'xi>fcl•1 r�il .rJ9111 �i r '1'.w1}Y�{ '' Pf't
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TAI''C " fitPtrJi'1.�?
by eta tz:.{ 17 fr '
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FINAC
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' ( { , .' ' —�`�L�. A AFI i•y'�
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• °,+ I , I a 't , .. � � , r _ .x c +i,k+ I I6nt1 Q.. r ,1 ,4
4'AV SIIITP 200 SAN MATQO nAUPOHNU 04404 2473 TIt LRP 11ONH(6110)377.0300 PA CSIMILQ 1640)349 2442 r,ry,"
l y_ , . r
r �D whirl Marnh I, 1-996
Sent 6y: ENGEO :NCORPORATED; 925 83B 7425 ; Fe0-15-00 2:19PM; Page 213
ENGEOGEOTLCMICAL ASI7D ENVIROt-MENT.4L CONSULTANTS
•I N C O R P O R A T E D MATERIALS TESTING
ProJct No,
4136.4.050.01
June 11, 1999
Mr.Pat Burke
The O'Brien Group
2001 Winward Way,Suite 266
San Mateo, CA 94404-2473
Subejet: Lot 5-35, Tract-Oak Valley
23577 Black Oak Way
Cupertino, California
SEISAllC FRAAIE,INSPECTIONS
Dear Mr.Burne•.
With your authorization, ENGEO incorporated performed special inspections related to the seismic
frame installation at the subject p,•operty location in Oak Valley in Cupertino, Califomia. This
report is submitted in accordance with Chapter 17 of the Uniform Building Code.
Observation services was provided using the approved plata for the following:
• • Shop welding of the seismic frames.
• Field welding of the seismic$ante moment connections.
Field welding or the framing straps.
• Grouting of the base plates.
To the best of our knowledge mtt 'lased on our observations,the work requiring special inspection
is in conformance with the approv,:d plans, field recommendations of the Structural Engineer, and
the applicable workr.-tanship provis'.ons of the Uniform Building Code.
We make no representation as to the accuracy of dimensions, calculations or any portion of the
design for this Project.
If you have any question or comment,please do not hesitate to contact our office.
Very truly yours,
ENGEO NgORPORA�TJZD /Reviewed
�by: �
Robert X. J imson Uri Eliahu
rzj/ce:seismic
cc: 1 —City of Cupertino
1 —The O'Brien Group,Mr.Gerry Ploof
• 2wl Crow Canml Ruud•9ulle 21111•Sul R:olon,CA 99587-1$1$•l' R1!* -: • Fa>;9251638-7&,N
H-moa:engsia,Mmngen,wo+•wMw.mgeaeUm
Sent By: ENGEO ?NCO.RPORA?ED; 525 838 7425 Fen-15-00 2:20P,d; Page 3/3
SRI SMIC FRAMF.TNSPF.CTTONS
Tract: Oak Valley
Sequence Number: 9
Lot Number: 5-35
Street Address: 23677 Black Oak Way
Shop Welding
Welding inspection in the field _
Field Frune Welding
Field Strap Wcldutg
• Base Plate Grout
Comply with the approved plans: Yes ® No ❑
Completion Date: June 11, 1999
•
D.aK vu day .Prr�.0 tel/f3 oNrct
.INSTALLATION CERTIFICATE (page 1 of 4) — CF-6R
erm-it um Fer
VIR Address
An installation cerliftcate is required to be posted at the building site or made available for all appropriate inspections. (Tete
information provided on this form is required;however,use of this form to provide the information is optional.) After
completion of final inspection,a copy must be provided to the building department(upon request)and the building owner at
occupancy,per Section 10-103(b).
. uvAr SYSTEMS•
Heating Equipment
Equip. gof Efficiency Duct Duel or Heating Heating
Type(pkg. CEC Certified Mfr Name Identical (AFUE,etc.)[ Location Piping Load Capacity
heat um and Model Number W F-IR v a I Tel attic etc.L R-value tu/hr (Btu/hr)
[.57 t
?ND F�Aat4[tE -3 BRAe/e70-i2 �1fL— G LIrs�
Cooling Equipment
Equip. CEC Certified Compressor g of Efficiency Duct Cooling Cooling
Type(pk& Unit Mfr Name and Identical (SEER etc.)[ Location Duct Load Capacity
hONWAAL
�eeat/,u�mModel Number S stems CF-IRvalue attic etc. R-value tulhr tuthr
lSJ - Z O� "Waaa
SND __7-- avr.�teo3 1_ /C 1. reads>_reads greater than or equal to.
1, the undersigned,verify that equipment listed above is: 1)is the actual equipment installed,2)equivalent to or more
efficient than that specified in the certificate of compliance(Form CF-IR) submitted for compliance with the Energy
Efficiency Standards for residential buildings,and 3)equipment that meets or exceeds the appropriate requirements for
•manufactured devices(from the Appliance Effcieney Regulations or Part.6),where applicable.
,/
Dil.�J 1�Q� Yor�
Signature.Date Installing Subcontractor(Co.Name)
OR General Contractor(Co.Name)OR Owner
WATER HEAMG SYCTEMS•
Distribution IfRecir- 4o Rated' Tank EfB- External
Heater CEC Certified Mfr Type(Std, eulation, Identical Input(kW Volume eleney' Standby' Insulation
Type Name&Model Number Pointaf--Usc) Control Type Systems or Btulhr) (gallons) (EF,AE) Loss(Y.) R-value
2 For small gas storage(rated input of less than or equal to 75,000 Btulhr),electric resistance and heat
pump water beaten,
Rated Input.Factor.
For large gas storage water heaters(rated input of greater than 75,000 Btufhr), Recovery Efficiency, y p
For instantaneous gas water beaten,list Recovery Efficiency and Rated Input
Faucets&Shower Heads:
All faucets and showerheads installed are certified to the Commission,pursuant to Title 24,Part 6,Subchapter 2,Section
Ill.
1,the undersigned, verify that equipment listed above my signature: 1) is the actual equipment installed;2) is equivalent
to or more efficient than that specified in the certificate of compliance (Form CF-IR)submitted for compliance with the
Energy Efficiency Standards for residential buildings;and 3)the equipment meets or exceeds the appropriate requirements
for manufactured devices(from the Appliance Efficiency Regulations or Part 6),where applicable.
• tgnature, ate
Installing Subcontractor(Co.Name)OR
General Contractor(Co.Name)OR Owner
COPY TO: Building Department
Building Owner at Occupancy