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11120100 (2) CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 19833 PORTAL PLZ CONTRACTOR:SUPREME AIR SYSTEMS PERMIT NO: 11120100 OWNER'S NAME: SPIVAK SANDRA G 80 GILMAN AVE STE 1 DATE ISSUED: 12/16/2011 OWNER'S PHONE: 4082573335 CAMPBELL,CA 95008 PHONE NO:(408)376-0406 LICENSED CONTRACTOR'S DECLARATION r r r L v� �� BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class C-26 Lie.N � MECH r RESIDENTIAL r COMMERCIAL r ContractoQy eww. A 1t. ate L 1 hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION: INSTALL NEW HEAT PUMP SYSTEM (commencing with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. 1 hereby affirm under penalty of perjury one of the following two declarations: 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. Sq.Ft Floor Area: Valuation:$15000 1 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. APN Number:36946030.00 Occupancy Type: APPLICANT CERTIFICATION I certify that 1 have read this application and state that the above information is correct.1 agree to comply with all city and county ordinances and state laws relating PERMIT EXPIRES IF WORK IS NOT STARTED to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR indemnify and keep harmless the City of Cupertino against liabilities,judgments, 18O DAYS FROM LAST CALLED INSPECTION. 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 sourc re ulationsp rth upertino Municipal Code,Section Issued b Datez/2-W—1/c S ural e Date RE-ROOFS: ❑ OWNER-BUILDER DECLARATION All roofs shall be inspected prior to any roofing material being installed.If a roof is installed without first obtaining an inspection,1 agree to remove all new materials for 1 hereby affirm that 1 am exempt from the Contractor's License Law for one or inspection. the following two reasons: 1,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date: will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) I,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have read the hazardous materials requirements under Chapter 6.95 orthe 1 have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& performance of the work for which this permit is issued. Safety Code,Section 25532(x)should I store or handle hazardous material. I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should 1 use equipment or devices which emit hazardous air Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the I certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534. not employ any person in my manner so as to become subject to the Worker's Owner or autho Compensation laws of California. If,after making this certificate of exemption,I D 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. 'CONSTRUCTIONLENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.) 1 certify that I have read this application and state that the above information is Lender's Name 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 Lender's Address upon the above mentioned property for inspection purposes.(We)agree to save indemnify and keep harmless the City of Cupertino against liabil itics,judgments, costs,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION granting of this permit.Additionally,the applicant understands and will comply 1 understand my plans shall be used as public records. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Licensed Professional Signature Date Al CITY OF CUPERTINO FEE ESTIMATOR— BUILDING DIVISION tADD..RESS: 19833 portal plaza DATE: 12/16/2011 REVIEWED BY: bobs. BP#: "VALUATION: $15,000 *PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition/ Repair PRIMARY SFD or Duplex PENTAMATION FURN/AC USE: PERMIT TYPE: At WORK install new heat pump system. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Heat Pump (<=10K cfm) 1 BREMAIR 1 # $65 TOTALS: $65.00 Meeh.Plan Check 0.0 hrs $0.00 Pknnb. Plan Check I"lee.Plan Che". Meeh. Penult Fee: IMPERMIT 1'[und�. Permit Fhe: Elec. Pern:ir Other Mech.Insp. 0.0 hrs $44.00 011:er Phwrb Lep. other I: CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 36946030. 00 DATE ISSUED. . . . . . . : 12/16/2011 RECEIPT #. . . . . . . . . : SS000015588 REFERENCE ID # . . . : 11120100 SITE ADDRESS . . . . . : 19833 PORTAL PLZ SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : SPIVAK SANDRA G ADDRESS . . . . . . . . . . : 19833 PORTAL PLZ CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-3367 RECEIVED FROM . . . . : SUPREME AIR SYSTEMS CONTRACTOR . . . . . . . : ALLEN SENNERT LIC # 21614 COMPANY . . . . . . . . . . : SUPREME AIR SYSTEMS ADDRESS . . . . . . . . . . : 80 GILMAN AVE STE 1 CITY/STATE/ZIP . . . : CAMPBELL, CA 95008 TELEPHONE . . . . . . . . : (408) 376-0406 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- -ADMIN HOURS 1.00 41. 00 0. 00 41. 00 0.00 1BCBSC VALUATION 15, 000.00 1. 00 0. 00 1. 00 0. 00 1BREMAIRHA NO.UNITS 1 .00 65. 00 0.00 65.00 0. 00 1BSEISMICR VALUATION 15, 000 .00 1. 50 0.00 1.50 0. 00 1MPERMITFE FLAT RATE 1. 00 44.00 0. 00 44 .00 0. 00 1TRAVDOC FLAT RATE 1. 00 44.00 0 . 00 44 .00 0.00 ---------- ---------- ---------- ---------- TOTAL PERMIT 196 .50 0 . 00 196.50 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 196 .50 #13995 --------------- TOTAL RECEIPT 196 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 ' FINAL MECHANICAL GENERAL PERMIT APPLICATION M E P COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 M I CUPERTINO (408)777-3228•FAX(408)777-3333•buildinG(a)cuoetno.oro SC PLUMBING MECHANICALELECTRICAL MISCELLANEOUS PROTECT ADDRESS APNs 1 _ / D OWNER NAbG PHONE EB. c_. S D 2 •-33s.S- -MA STREET ADDRESS G n�L: /S Z CITY, STAB.ZQ' q ,) --,e FAX coNTACT NAME / O �/-' I` PHOTlEE`HAU•� O L J STREET ADORES ( CITY,STATE, Z@ FAX (;In /f L4 -a0 f r op,376 GSC L ❑OWNER ❑ owNBR-BVBDER ❑ OWNER AGENT VCONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHrTECT ❑ENGDIEEN ❑ DEVEoPES ❑TENANT CONTRACTOR NA�J �� ` r LICENSE .� LICENSE Z BUS.LIC e v YC.VW-, ✓L U COMPANY NAME E. FAX N^Q— r STAEETADDRESS CITY,STATE,ZII' PHONE ARCIOTECT/lENODrEEB NAMH IlCENSE NUMBER BUS.LIC a COMPANY NAME E-MAIL FAX STREET ADORES$ CRY.STATE,ZIP PHONE USE OF wDUPLIX ❑ MULTI-FAMMY PROJECT IN WIDJAND ❑ YES PROJECTIN ❑YES ISTHEBJDGAN ❑YES BU .WNG: ❑COMtCERCW. URBAN INTERFACT AREA [3 NO FLOOD ZONE [3 No ETCHER.HOME) ❑NO DESCRIPTION OF WORK TOTALVALUATION: / DUU RECEIVED BY: By Ory signature below,I cato to each of the fallowing: I am the property owner or authorirsd agent to act on the property owner's behalf I have read this application and the informadon I have provided is correct have toad the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building c sduct Snthmi represcatadves of Cupertino to cater the above-idca ed pro for inspecdoB puf�lses. Signature of ApplicanHADare: 2- SUPPLEMENT-AL JFORMATI N REQUIRED OFFICE USE ONLY m ❑ OVER-THE-COUNTER 6 y ❑ EXPRESS U 2 ❑ STANDARD U ❑ LARGE r ❑ MAJOR MEPMscApp_2011.doc revised 06/21/11 w. • r,1,. MITSUBISHI / WAL11M. ELECTRIC ®� Split-ductless A/C and Hest Pumps SUBMITTAL DATA: 1MULTI-INDOOR Job Name: Location: Date: Purchaser. Engineer. Submitted to: For ❑Reference []Approval ❑Construction Unit Designation: Schedule No.: GENERAL FEATURES - Electrical Requirements •O - ---�•' Power Supply . ......208/230V, 1-Phase, 60 HZ Impact side discharge outdoor 1,., ', -� + PPy de• B Recommended FuseBreaker Size... ........ . ...........20 A •Wireless or wired remote controller, ®' MCA................. ................ .. ... . ..... . 15A depending on the indoor units used ! Voltage • Quiet operator—both indoor and t, Indoor-Outdoor S1-S2 . ..... .. . . . . .. . .. .. . . . AC 208/230V outdoor units ( � Automatic fan speed control Indoor-Outdoor S2-63 . ..... .. . .. . .. ... ... .. . .DC 12-24V • •Auto restart following Power outageOPERATING RANGE lfc •Seheck function--intfunction--integratedonntegrated I" Irdoor)rolm MTenp. aedoorlrtalm AtrTerrp. diagnostics v Maximum 89F(39C)OB,71"F(f2 V.8 115•F(4M)DB .Advanced microprocessor control ;g,�++3`'�T`"' �Ilns •Limited warranty:five years on parts and �C Minimum 67°F(19'L7 DB,57°F D4'C)we 14•F(-1("C)DB defects and seven years on compressors, Outdoor Unit:MXZJB30NA Maximum 8DF(27'C)DB,67"F(19"LM 79FR4"C)MWF(1&QV,8 OPTIONAL OUTDOOR UNIT ACCESSORIES Heating Minimum 70F(21-QDK6IrF(1IsQM 6°F(-141QDB,S-FE19G7w6 •Air Outlet Guide(MAC-856SG) •3/8"x 12"Port Adapter AC-A454JP Compressor............ ... ... DC Inverter-driven Twin Rotary •12"x3!8"Part Adapter C-A455JP-E Fan Motor. ....... ... . .. ..... ... .. ... . .. ... .. . 0.93 FLA •12"x Sla"Port Adapter AC.A456JP-E Sound Pressure Level •1/4"x 3/8"Port Adapter PAC-SG76 Conlin (Non-ducted/Ducted ... . ............. .. .. . .49 dB(A) •3/8"x Sl8"Port Adapter PA65G76RJ-E) Heating( Cooling* DIMENSIONS JINCHESIMM Rated Capacity(Non-ducted/Ducted)...28,400 Btum/27,400 Btu/h W 38-7/16/eon Minimum Ca dty(Nonduded0ucted) ..12,600 Blum/12,600 Btum it Total Input(Non-dudecUDuded).... ..........3,120 W/3,330 W I D I 12.518 1 321 Heating at 47"Fa H135-7/16 1 900 Rated Capacity(Nonduded/Duded). ..28,600 Btum/27,600 Btum Weight ...:.. . .. ... .. . .. .. . . . . .. . .. .... .150 lbs./68 Minimum CapPacity(NorFduded/Duded). . 11,400 Btum/11,400 Btu/h Extemai Finish . .. ... ... .... ... . .. . ..Munsell No. 3Y 7.8 114 Total Input(Non-dudedlDuded). .. . .I ... ... ..2,150 W/2,220 W Refrigerant Type... . .. .. . ..... .. . .. . .. ..... . .. .... R410A Heating at ITP" Refrigerant Pipe S6 O.D.—Three Ports Rated Capacity(Nonducted/Ducted)...16,000 Btum 115,100 Blum Gas Side.... .. ... .. . ... A 117'/12.7mm;B,C: 3/8"/9.52 mm Total Input(Non-ducted/Ducted). ... .... ....2,120 W/2,190 W Liquid Side............. . ... ....... ... .....114"/6.35 mm •Rd6p Condinra(Ccntno)-indoor:BUT RM DO 76TF(IM We.outdoor.95•F(W-C) Max.Refrigerant Pipe Length. ... .......... .. .... .230'/70 m as 176•F(24'Q Wa Max.Piping Length for Each Indoor Unit..... .. ... . ..82'/25 m elsung)-Indoor.7ofRrcloB/wcF(IMVVB.owdoor:47f(Buq DB/4aflsgM. Max.Refrigerant Pipe Height Difference sleotingat 1717-indoor.701-(2MDB(E01=(1e" vWLaajo ..I7T(4•C)DS/15T If Indoor Unit is Above Outdoor Unit. ........... .. .. 49'115m (-M WE). If Indoor Unh is Below Outdoor Unit. ........... .. .. 33'/10 m (Fordateonapecmclndoorun)tafellducted,aimm-ducted,and both ducted Connection Method . . .. .......... ............ .. ....Flared arid non-ductar0combirati u saelhelrechnicaland Service Manuals.) COMPATIBLE INDOOR UNITS AND ASSOCIATED REMOTE CONTROLLERS MXZ-3830NA ENERGY EFFICIENCIES Horlmntal-ducted Indoor Unita:SEZ-KD09,12,18,1li&PEADA24AA —, Indoor nit COP @ COP @ — Remote Controller PAR-2IMAA- Type SEER EER HSPF 47•F 171F Packaged with SEZ and PEAD Non-dueled 17.5 8.1 10.5 3.B 2.77 OB+06+09 Dueled and 16 8.7 10.0 3,8 2.775 Non-ducted Wallanamted Indoor Units:M8ZGE06,09,12,15,18NA,MSZ4rA24NA Ducted 09+09+08 14.5 8.2 9.5 3.64 2.78 Wirelea Remote Controller fppE Ved wth M8r MRtpbonaWk ndatl Indoor Units: Cellingrsssette Indoor Units: PAR2IMAARenoeContmpmr) Calling-suspe PCA-A24KA RPL�AA18,24BA IMall noMSZ- untetl oor IntlUnits: FloorabnOing Indoor Units: MSZf E09,12NA MF2-KA08,12,18NA i i s',all � Remote Conimter PAR-21W_ -"" O _ Packegedwith PCA-A24KA and PLA-A18,24BA I I t R Ruler b(heseparate sultM0a1 bmla for tl1e8EZ,PFAD,MS2:MFZ,PCA,and PLA/Moor Units. 1 • MXZ-31330NA enne 7aro- Unit: inch 8.27/32' 10-510' 1 3/8'. l0 2-U Shaped nal had hole �Aa in IBembalt M10) N n —a urNp e ' uS Drain hole 3$1-5116• B Atr an � ra 241 SW x 1.13132oval hole (Been ban M10) 3 7RYunched hole annex vennp e 35-7/16' 2-$7/8'Knockaut 3/31-3/16- 12.1 OUT 17 Handle r(Conned wldnp hale) Haondl .o Gee pi owe" 3/B ,C unI 31527 $12 Auna C unit connection } B unit connection d } Aunit connection 291 yN' tl 55 1.Installation apace Note:Leave both aides d free of obstruction. ;Lock M then 315116' tz i�3- 00aMae men 19-11/Ir Note:Leave overhead free of obstruction. Connector Condun cover More lhan 315/18• 0 Mae man13252r Maro men 19-11116' 2.Service space77777777 io � m 5 d Mare men 316118' SERVICE SPACE Mae than 13-25132' More than 132527 AAMITSUBISHI k ELECTRIC HVAC Advanced Products Division 34001awrencew'Oa Suwenee Rd Suwanes,GA 30024 (f�7gt) ® Tele:618376.2900•Fmr.8003883904 Toll Free:800.433-4822(113) www.mehwrc.com CSD-MXZaB30NAfor Multiple Indoor Unit Styles -201005 ®MITSUBISHI ELECTRIC HVAC 2010 Specifications are subject to change without notice. �nles-�- Co vv, rn � v) W t ► �� fol - T i LA- - x ; R� i DEC 16 2011 9 Associao' Egg M&C Association Management Services, Inc. December 12, 2011 Re: Architectural Modification Application To whom it may concern: Please see the attached approved Homeowners Association's Architectural Modification for the installation of the Mitsubishi system. Thank you, Biff Geiser , Sr. Community Manager 17 M & C Association Management Services, Inc., cv RF:CEIVF,D DEC 16 2011 BY:� 4305 Hacienda Dr.0180,Pleasanton,California 94588 Telephone 408.241.0023 Fax 408.241.0093 Web www.mccommunfties.com Associao I The nation's leader in community association management I www.associaonline.com 1 800.808.4882 PORTAL PLAZA HOMEOWNERSASSOCIATION APPLICATION TO MODIFY PROPERTY EXTERIOR OR COMMON ELEMENTS WITHIN OR SERVING UNIT Please describe all changes you propose to make to your home or on your lot. Include a scale drawing with top and side views (pian and elevation) as necessary to clearly establish locations and elevations of any structures. Include dimensions and description of materials, and specify color(s) if appropriate. Your drawing should include exisfing structures and boundaries where necessary to Indicate relative location. Photographs may be acceptable for some applications. Contractors must be licensed and may be asked to provide acceptable evidence of Insurance. Permits and compliance with building and safety codes are the responsibility of the owner and may be required. To avoid delay of approval please include all the information that the Architectural Committee will need to make a decision. Attach additional pages If needed. Your application must be signed and dated below and on the attached Acknowledgment of Responsibility. Professional review and/or extensive scrutiny of contracts and plans may be required for significant or structural modifications. You may deliver this completed form along with drawings to M & C Association Management, 4305 Hacienda Drive, Suite 180, Pleasanton, CA 94588; or FAX (408) 241-0093. A copy of the form will be returned to you shortly with the bottom portion completed as your receipt. Owners: Sandra Spivak Address: 19833 Portal Plaza Cupertino CA 95014 Daytime Number. 408-257-3335 Evening Number. Description of Proposed Modification: Per Ass. Board site review, the leader piping and rn;\k J � electrical will go to inside walls below the fence line to b Tic^ avoid view from outside private yard. The Mitsubishi VRF system being installed is a climate &air quality controlled ductless HVAC System chosen for these benefits due to health reasons. Signature: Raymond Scott[Contractor) Date: 12-09-11 Print Name: Sandra Spivak Unit#: 19833 Affachmenl(s): ❑ Contract ❑ Plan/Elevation xProd,vr+r-f-rrnation 0 Detall/Dimension )OXAw,v`fr ❑ Certificate of Insurance ❑ Acknowledgement of Responsibility ❑ Other The ccLrs of your Alsoewon contaln fids infomuafion for archltectural torrid.Please read them carefully and refer to them when applying for any architectural modification. The Board of Directors has reviewed the proposed exterior changes to your unit as outlined above, and grants approval for you to proceed with the work, subject to the plans that were submitted, use of a licensed and insured contractor, and the ANN-Page 1 ❑ Your application has been denied. Reason: ❑ Your application is being returned for additional information. Forms Needed: Signed by: Title: Al Eg-- Dated: 2 —co— 1 Attach all applicable above-referenced documents.See attached Instructions for additional Information. "'R applicable please remember to attach the signed and dated Satellite Dish Installation Guidelines or Window Replacement guidelines. AMRF-Page 2 Prescriptive Certificate of Compliance:Residential CF-IR-ALT Residential Alterations (Page 4 of 5 Project Name: Climate Zone 0 q of Stories HVAC SYSTEMS-HEATING Minimum Duct or Piping Configuration Heating Equipment Etlicien Distribution Insulation Thermostat (Central,Split, Type and Ca aci n•z' AFUE HSPF T d Location' R-Value Type Space.Package or^H dronic /.Indicate Hewing Type(Central Furnace, Wall Furnace,Heat pump,Boiler,Electric Resistance,etc.) 2.Electric resistance heating is allowed only in Component Package C, or except where electric heating is supplemental(.e.,if total capacity <2 KW or 7,000 Btu/hr electric heating is controlled by a time-limiting device not exceeding 30 minutes). See§151(b)3 exception. 3.Refer to the HERS Verification section an Page 4 of the CF-IR-ALT Form for additional requirements and check applicable boxes. 4. Indicate Type or Location(Ducts,Hydrant in Floor,Radiators,etc.) HVAC SYSTEMS-COOLING Minimum cY Duct or Piping Configuration Cooling Equipment (SEE R or Distribution Insulation Thermostat (Central,Split, T e and Capacity'.2 COP) Type and Location R-Value Tvue S acePackage or H dronic 1.Incbcare Cooling Type(A/C,Heat pump,Evmp. Cooling,etc) 2.Refer to the HERS Verification section on Page 4 of the CF-IR ALT Form for additional requirements and check applicable boxes. 3.I ndicatee or Location cis,H tunic in Floor,Radiators,etc. WATER HEATING List water heaters and boilers for both domestic hot water(DHW)heaters andhydronic space heating. Individual dwelling DHW heaters must be gas or propane fired Hot water pipe insulation from the DHW heater to the kitchen(s)and on all underground hot water pipes is required in all component packages in all climate zones. External Tank Water Heater Type/Fuel Distribution Type Number In Tank Energy Factor or Insulation Type, (Standard,Recirculating)' System Capacity al Thermal Efficiency R-Value' 1.Indicate Type(Storage Gas,Heat Pump,Instantaneous,etc.) 2.Recirculating systems serving multiple dwelling units shall meet the recirculation requirements of§150(n). The Prescriptive requirethen s d1F I not allow the installation of a recirculating water heating system for single dwelling units. 3. The external water heating tank and pipes shall be insulated to meet the requirements o 150 - r-.M SPECIAL FEATURES The enforcement agency should pay special attention to the Special Features specified in this checklist below. a These items may require written 'ustl cation and documentation and special verification, NEW ROOF ASSEMBLY-Radiant Barrier The radiant barrier uirement of I51 2 does not I to roof alterations. ,tin's Slab Edge(Perimeter)Insulation YES NO ,: > YES:In Climate Zone 16 in Component Packages D,R-7 insulation is required. r ,� Heated Slab Insulation 0 YES EINO YES:Slab edRe insulation re rSed for all heated slabs in all Climate Zones. See details in Table 118-A of the standards. e x Raised Slab Insulation YES NO y� YES:In Climate Zones 1 2 11 13 14& 16 R-8 insulation is d;in Climate Zones 12&15 R-4 is re rdPRln Thermal Mass To obtain Compliance Credit for the installation of thermal mass use the Performance Approach. DEC 16 RegistratlonN=- ber: Registr'dgonDale/JYme•;'- • - HERSProvider.:, •- <t. - -m--- 2008 Residential Compliance Forms March 2010 Prescriptive Certificate of Compliance: Residential CF-IR-ALT Residential Alterations age 5 of 5 Project Name: �., Climate Zone 0 N of Stories v� HERS VERIFICATION SUMMARY The enforcement agency should pay special attention to the HERSMeasures specified in this checklist below. A completed and signed CF-4R Form for all the measures specified shall be submitted to the building inspector before final ins ection, DuctSealln & Testing HERS verificationisrequiredforthis measure. ❑YES NO YES:In Climate Zones 2 and 9-16,if more than 40 linear feet of new or replacement ducts are installed in unconditioned space,the ducts are to be sealed per§152(b)1Dii and the newly installed ducts are to be insulated per§15l(f)10. ❑ EXCEPTION:Existing duct systems that are extended,which are constructed,insulated or sealed with asbestos. DYES NO YES:In Climate Zones 2 and 9-16,if the existing space-conditioning system(HVAC equipment and ducting)is replaced,the 0 //// ducts me to be sealed per§152(b)1Di. E]YES �INO YES:In Climate Zones 2 and 9-16,if the existing HVAC equipment is replaced(including the replacement of the air handler, outdoor condensing unit of a split system,cooling or heating coil,or the furnace heat exchanger)the ducts are to be sealed per§152(b)1E. ❑ EXCEPTION:Duct systems that are documented to have been previously sealed confirmed through HERS verification in accordance with procedures in the Reference Residential Appendix RA3. ❑ EXCEPTION:Duct systems with less than 40 linear feet in unconditioned apace. rl EXCEPTION:Existing ducts stems constructed,insulated or sealed with asbestos. Refrigerat{Charge-Split System HERS verification is requiredfor this measure. ❑YES Ipl NO YES:In Climate Zones 2 and 8-15,when the existing HVAC equipment is replaced(including the replacement of the air t handler,outdoor condensing unit of a split system A/C or heat pump,cooling or heating cod,or the furnace heat exchanger)a refrigerant charge measurement shall be verified per 152(6)1F. Central Fan Integrated (CF1)Ventilation System and Fan Watt Draw The ventilation requirements of§150 o do not apply to existing residential homes. Ducted Sp 1. 'Systema-Air Conditioners and Heat Pumps:Airflow HERS verification is required for this measure. ❑YES NO YES:In Climate Zones 10 through 15,when the existing space-conditioning system(HVAC equipment and ducting)is replaced,the airflow and fan watt draw shall be verified per§152 1 Ci to meet therequirements of§15l(f)7B. Documentation Author's Declaration Statement • I certify that this Certificate of Compliance documentation is accurate and corn Icte. Name: // Signature: Company: ate: Address: - If Applicable UCEA or CEPE �17 v' WI01 (Certification l!): City/StateMp: , Phone: Responsible Building igner's Declaration Statement • I am eligible under Division 3 of the California Business and Professions Code to accept responsibility for the building design identified on this Certificate of Compliance. . I certify that the energy features and performance specifications for the building design identified on this Cert'if'icate of Compliance conform to the requirements of Title 24,Parts I and 6 of the California Code of Regulations. • The building design features identified on this Certificate of Compliance are consistent with the information provided to document this building design on the other applicable compliance forms,worksheets,calculations,plans and specifications submitted to the enforcement agency for=noval with this buildinit permit application. Name: //a. GG' Company: Date: / / t2 Sc Address: L� � License: -2 t1 V City/State/Zip: Phone: o - 'S Oe For assistance or quer ' ns regarding the Energy Standards,contact the End HotNne at:1-800.772-3300. Regotr6non,Numbece",t• -...' -.._ '� . . RegistmtionDate/71me: _HERSProwder .. : . 2008 Residential Compliance Forms March 2010 Building Department City Of Cupertino 10300 Torre Avenue Cupertino,CA 95014-3255 Telephone: 408-777-3228 C U P E RTI N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: Z PERMIT# 20 0 0 OWNER'SNAME: AlrzPHiNE# o rr .3�6 o b 6 GENERAL CONTRACTOR: BUSINESS LICENSE# ADDRESS: 6ch CITY/ZIPCODE: (A ca *Our municipal code requires all businesses working in the city to have a City of Cuperti o business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTQJRS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Z E �gnature Da e Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring/ Carpeting Linoleum / Wood Glass/Glazing Heating Insulation Landscaping Lathing Masonry Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date