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10110047CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20902 DUNBAR DR OWNER'S NAME: THEODORE M CHAO OWNER'S PHONE: 7022776522 ❑ LICENSED CONTRACTOR'S DECLARATION License Class Lic. # Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain a certificate of consent to self -insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature CONTRACTOR: THEODORE M CHAO PERMIT NO: 10110047 598 VALERI RUTH CT DATE ISSUED: 05/20/2011 SANTA CLARA, CA 95050 IPHONENO: BUILDING PERMIT INFO: BLDG F ELECT r PLUMB r MECH r RESIDENTIAL r COMMERCIAL r JOB DESCRIPTION: NEW SFDWL 3,817SQ-LIVING,494SQ- GARAGE;LANDSCAPE 1,782SQ Sq. Ft Floor Area: I Valuation: $812800 APN Number: 32630141.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Date I Issued bye Date:–E— 2.D , 11 ae OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). 1 hereby affirm under penalty of perjury one of the following three 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. I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If, after making this certificate of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoke �L APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non-poin� re ulations p�upertino Municipal Code, Section 9.18. Signature Date RE -ROOFS: 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 inspection. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(x) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. rb Date: VZ�Z4 / CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency for the performance of mork's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Add ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional CITY OF CUPERTINO BUILDING PERM%n J BUILDING ADDRESS: 20902 DUNBAR DR CONTRACTOR: THEODORE M CHAO PERMIT NO: 10110047 OWNER'S NAME: THEODORE M CHAO 598 VALERI RUTH CT DATE ISSUED: 05/20/2011 OWNER'S PHONE: 7022776522 SANTA CLARA, CA 95050 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION r F (— BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic. # MECH F RESIDENTIAL COMMERCIAL Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: NEW SFDWL 3,817SQ-LIVING,494SQ- (commencing with Section 7000) of Division 3 of the Business &Professions Code and that my license is in full force and effect. GARAGE;LANDSCAPE 1 782SQ � �q!-I'a � Q�� j ✓r �-e �//� L �Qt s�.2 3// -! _ / /�" n I herebyaffirm under penalty of perjury one of the following two declarations: P tY pe 1 r'Y g - D`v�.�J �`ys �A-GZ �`.I'°� I have and will maintain a certificate of consent to self -insure for Worker's ROD,- //t V /.X� ✓� "`� Compensation, as provided for by Section 3700 of the Labor Code, for the (y �- &1-7111 performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this Sq. Ft Floor Area: Valuation: $812800 permit is issued. APPLICANT CERTIFICATION APN Number: 32630141.00 Occupancy Type: I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, PERMIT EXPIRES IF WORK IS NOT STARTED costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR with all non -point source regulations per the Cupertino Municipal Code, Section 180 DAYS FROM LAST CALLED INSPECTION. 9.18. Signature Date Issued b Date: i OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of RE -ROOFS: the following two reasons: '--41( All roofs shall be inspected prior to any roofing material berg installed. If a roof is 1, as owner of the property, or my employees with wages as their sole compensation, installed without first obtaining an inspection, I agree to remove all new materials for will do the work, and the structure is not intended or offered for sale (Sec.7044, inspection. Business & Professions Code) . I, as owner of the property, am exclusively contracting with licensed contractors to Signature of A-pphcaffW.., Date: construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three cd, ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER declarations: I have and will maintain a Certificate of Consent to self -insure for Worker's HAZARDOUS MATERIALS DISCLOSURE Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain Worker's Compensation Insurance, as provided for by California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain Section 3700 of the Labor Code, for the performance of the work for which this compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(x) should I store or handle hazardous material. permit is issued. Additionally, should I use equipment or devices which emit hazardous air I certify that in the performance of the work for which this permit is issued, I shall contaminants as defined by the Bay Area Air Quality Management District I will not employ any person in any manner so as to become subject to the Worker's maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Compensation laws of California. If, after making this certificate of exemption, I Health & Safety Code, Sections 25505, 25533, and 25534. 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. Own r or authoop d agent: �­::11-_Date:zG�� APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating I hereby affirm that there is a construction lending agency for the performance of work's to building construction, and hereby authorize representatives of this city to enter for which this permit is issued (Sec. 3097, Civ C.) upon the above mentioned property for inspection purposes. (We) agree to save Lender's Name indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the Lender's Address granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section ARCHITECT'S DECLARATION 9.18. ��� �```' � 7 L`� I understand my plans shall be used as public records. Signature Date 7 ec L CA" Licensed Professional CITY OF CUPERTINO /-0/ CITY OF CUPERTINO NEW SINGLE/MULTI FAMILY DWELLING PERMIT APPLICATION FORM / 00 Y7 APN # ` L �-3u ,I4, f Date: Are you adding a 2" unit? Yes ❑ No If yes, You also need to fill out the permit application for a 2nd unit. Building Address: 2070 v DUNBAR OPIVt 1_UPER7_I1/0 GA , , Mailing Address (if different from building add-!�sc): S?S- San-VACJa -ai CA- ?Sato Owner's Name:ii Phone #: `f ` I hetodpre- M- 1 ��,, 6,0 a Do you have the planning Residential Design Review/Minor Residential Permit approval? Yes ❑ No If yes, please provide a copy of your planning approval letter. Planners Name: If no, see Planning before submitting plans to the Building Department. Have you applied for the demolition permit? Yes NoX Applicant Signature (Notified of Demo If no, pick up application and procedures. Requirements): Contractor: Phone #: Fax #: Cupertino Business License #: State Contractor License #: Contact: 1Hr Mifke c4eH(10M.C. Assvc,c4fcs, LLP) Phone #: 40$ -44K-941F, Fax#: *og -404 -603-2 Landscape Ordinance Compliance: Landscape area in sq. ft. (includes all irrigated areas): 1,7 9 Z If 2,500 sq. ft. or less, compliance with the Landscape Water -Efficiency Checklist is required. If more than 2,500 sq. ft., a complete Landscape Project Submittal is required. Compliance Method: ❑ Plant Type © Water Budget Single -Story ® Two -Story ❑ Three -Story ❑ Basement ❑ Hillside ❑ ❑ Apartment ❑ Condo ❑ Townhouse ❑ --Multi-family Sq.Ft. Living Area -Including Basement & Attached Garage: Sq. Ft. Garage (Detached Only): Living area: 3,817 Basement: Attached Garage: 9 4 Total Sq. Ft: -7 i 1 Job Description: New S: Fc, D wc I I - 5 fo r Type of C nstruction (Usage Cl s): Occupancy Type: R 3 4 U 1-A, I -B ❑ 1I/111/V-A ❑ lI/III B, IV -HT, V -B © Valuation: g 12 Project Size: Standard W Lar e❑ Major ❑ Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the application or if applicable, include in plan set & the sheet index. Green Building Points Achieved: For help, contact Build it Green at www.build it reen.or Revised 05/18/10 CUPERTINO CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildinge-cugertino.org LJ NEW CONSTRUCTION LJ ADDITION LJ ALTERATION / Ti LJ REVISION / DEFERRED ORIGINAL PERMIT # O / f0o 4 7 PROJECT ADDRESS J D 4 �GCX Na'r i✓ Y APN H `7 z 7 6 O OWNER NAME / / PHONE E-MAIL Glacev c# -?-33 - � TS" T/abv . CHIu su STREET ADDRESS CITY, STATE, ZIP FAX CONTACT NAME t4 if PHONE E-MAIL C/a�f d o -7 7 cN,q0 1-16) Al 6 7-w ANao. �c STREET ADDRESS CITY, STATE, ZIP FAX rd A vc v . / / V & et 1:.? IX OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTORAGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAMELICENSE NUMBER LICENSE TYPE BUS. LIC H ,odoyc 4(. GH�o (Owx B.;id COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC H -ZA/ N MC ASSOGiA4- LLP COMPANY NAME ,� .j E-MAIL hiMc G fEaw r L ( l� 7H i 6 [C a 1I STREET ADDRESS CITY, STATE, ZIP PHONE 4, Vint Wd a Lo7 s yc�t, a CA Leo DESCRIPTION OF WORK OF 0 AJd post" toe W14 j FU)?AVC6' 6, I IQI:t t� �f�•c�ot •ry �fsrl %e wQsry Mup pcov'14/ ( A0A,'P,?r k oo y S�uc( �� � ` Add 4.4v U/,.!/s a- g,a X -A C4 `"ate t� ve-%t A-4 doerc it We zi•,l/ ,I,, Cr.eo.i sP, EXISTING USE PROPOSED USE CONSTR. TYPE X STORIES V Add Air Sf— 6= Aft -cam Y AcAd Vt.,pP� &. aYaw/ spec+ DW,�App= of � . uuc r -VISCU vj? ui � � ZA Ga,.�k, Dv..N• s� ca%/.�, f ��c B.tjQ rvo�.� fvvt., yet �/ '03 4A... c.. sv-z fs�G �7( Lo*.s>s %`,, CUPERTINO PURPOSE UTILITY RELEASE REQUEST FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building aOcupertino.org For residential single family or duplex construction, there are cases where gas and electric utilities are requested to be released prior to the issuance of the certificate of occupancy. Upon approval from the building inspector, the City of Cupertino is allowing both utilities to be released prior to the final sign -off of the building. INSTRUCTIONS 1. Download this form at: http://www.cupertino.or index.aspx?page=297. 2. Complete the form and obtain signatures from both the owner of the property and the primary contractor. 3. Fax, E -Mail, Mail or hand deliver the original signed form to: City of Cupertino Building Division Attn: Utility Release Request Form 408-777-3228 office 10300 Torre Ave. 408-777-3333 fax Cupertino, CA 95014 building_na,cupertino.org Schedule a Gas Meter Release inspection (#403) and/or Electric Meter Release inspection (#404). Please note, a Gas Test inspection (#506) is required prior to or at the same time of the Gas Meter Release inspection. BUILDING INFORMATION (Please complete the following information): r . v BLDG PERMIT #: O DATE: I SITE ADDRES C5 L OWNER'S NA E: PHONE* � Q FAX #:9 5a 2-7 MAILING ADDRESS (if different from site address): CONT PHONE #: FAX #: CONTACT: PHONE #: FAX #: I request the City to release my utilities prior to obtaining a final inspection approval for the building. I fully understand the occupants of the building cannot move into the residence until they receive all of the required final sign -offs and the City has issued a certificate of occupancy for the building. b' i-%.sl.:�!.""'— Nu Glace T�.eoalore GNA6.....Date:./!�Z��.Z........ Owner....!ri............... Print:..................... . o►' '/ ZOdo vc M, C 4A p Contractor: ..................................... ........................................ Print:......................................................................... Date:.............................. UtilityReleaseForm_2011.doc revised 08/09/11 Cl a ALTERNATE MATERIALS AND METHODS / . if TN FORM COMMUNITY DEVELOPMENTDEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 4� n i,- 2 � �°°� ')� (408) 777-3228 • FAX (408) 777-3333 • buildincl aDcupertino.org REQUEST FOR MODIFICATION OF CODE (CBC 104.10) W—REQUEST FOR ALTERNATE MATERIAL, DESIGN OR METHOD OF CONSTRUCTION (CBC 104.11, CFC 111.2.4) To at)Dly for this reauest, complete sections 1, 2, 8 3 (ink or type) SITE ADDRESS 2-0 / 0Z ��vA f APN p J / _ 3� '4 [� DATE Owner... .... /..:.1-.......................................................................... *: ..................................... Type:.............../..................... G`' `r JJ � ^PC Address.$ 0....! '.14 f r.... R.KT..4-S(T�.....�r�`!.... `� 5.195-z>. .................... 0 0 1.....�.�...........7....... S; 1¢ Stories:.............................. �/ _Permit Email......?..rJ'(`!`;-.Phone..�.�.1.3�1...�.s...PLN #: K.� Attach additional sheets if necessary. #:................................... Dept./Div ................................ Occupancy:... .............. Floor Area:... 3. �..... ....... / l a 'kr...... Applicant . i f' ..../.,. q .... .................Title . .�rl✓ ...la... Address............................................................................................................ ................. Job Status:............................ Occ. Load: ............................. � �d�A� Use of Bldg:.�S.'......... -........ Email.......................................................................Phone................................ .............. u 2 REQUEST: For code modifications, please state the applicable code requirement and the extent of relief desired. For alternate requests, state the type of system proposed and desi n methods. Submit plans if necessary to illustrate request. Additional sheets or data may be attached, i q nc `rnZ nwCdeor Uf pr er ra-r r-'10^ -to f -14e. 't s :a -c- -to e ejdo- L�►'� s42,-,1 411.6 d,,,r-s s�41( o Wx I ka✓ M e\^qA, resistance, durability, safety and sanitation that is equivalent to the code for a similar use. 3 JUSTIFICATION/FINDINGS OF EQUIVALENCY: For code modifications, applicant shall demonstrate that Code Section(s): CONDITIONS OF APPROVAL: special, individual reasons exist that make compliance with the strict letter of the ordinance impractical and that equivalency is provided. For alternate requests, applicant shall demonstrate suitability, strength, effectiveness, fire y " resistance, durability, safety and sanitation that is equivalent to the code for a similar use. Attach additional sheets if necessary. Al Alt( c,,4ad "j r. ;r�bN v u ,�pp yQ �/ ......�.It'..�f..Print:...L412-).zy............... ,.p '..! `, ....Date:.f1..L:;.- I....... FireMarshal: .................................................. Petitioner's �w i7�J(l Reviewed Si nature: `................ Position: T�gu.� —Date: By: .....................................................Date:.....�.�, The Request is: ❑ GRANTED ❑ DENIED De t. Comments:� CONDITIONS OF APPROVAL: y " No. of Items:........... Fee Due: Date Paid: ................................ Receipt No,: .............................. Processed by:..........`.................. ;r�bN v Building Official : .. ............. ..... ,�pp yQ �/ ......�.It'..�f..Print:...L412-).zy............... ,.p '..! `, ....Date:.f1..L:;.- I....... FireMarshal: .................................................. 0 ..................................... Print: .... ...... . ....................... Date: ........................... DEPARTMENT ACTION: After determination, copies to: 1) applicant, 2) permit file Altform_2010.doc revised 06/11/10 ITEM 1 OF 1 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 32630141.00 DATE ISSUED.......: 08/25/2011 RECEIPT #.........: BS000014567 REFERENCE ID # ...: 10110047 SITE ADDRESS ..... SUBDIVISION ...... CITY ............. IMPACT AREA ...... OWNER ............ ADDRESS .......... CITY/STATE/ZIP ... RECEIVED FROM .... CONTRACTOR ....... COMPANY .......... ADDRESS ..........: CITY/STATE/ZIP ... TELEPHONE ........: FEE ID UNIT QUANTITY ---------- lALTMAT ------------- HOURS ---------- 1.00 1BCBSC VALUATION 812,800.00 1BCONSTAXR FLAT RATE 1.00 1BSEISMICR VALUATION 812,800.00 1PLLONGR SQUARE FEET 4,311.00 1R3INSP SQUARE FEET 4,311.00 1R3PLNCK SQUARE FEET 4,311.00 1REVSFDWL EACH 1.00 TOTAL PERMIT : METHOD OF PAYMENT ----------------- CREDIT CARD TOTAL RECEIPT : 20902 DUNBAR DR CUPERTINO THEODORE M CHAO 598 VALERI RUTH CT SANTA CLARA, CA 95050 THEODORE CHAO LIC # *OWNER* THEODORE M CHAO 598 VALERI RUTH CT SANTA CLARA, CA 95050 AMOUNT --------------- 170.00 --------------- 170.00 AMOUNT 170.00 33.00 558.42 81.28 560.43 3303.72 2924.36 760.00 8391.21 PD -TO -DT 0.00 33.00 558.42 81.28 560.43 3303.72 2924.36 760.00 8221.21 OPERATOR: patg COPY # : 1 THIS REC NEW BAL 170.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 REFERENCE NUMBER -------------------- VISA 170.00 0.00 1 CITY OF CUPERTINO FM_7 FEE ESTIMATOR - BUILDING DIVISION iAADDRESS: 20902 dunbar dr. DATE: 08/25/2011 REVIEWED BY: bobs. APN: BP#: "VALUATION: Iso *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex USE: PENTAMATION 1GENRES PERMIT TYPE: 14 wORK alternate materials and methods/modification of the new master bathroom. SCOPE PME Plan Check: NOTE: These fees are horsed on the Dreliminary information available and are onlv an estimate. Contact the Dent for addn'1 info. FEE ITEMS (Fee Resolution 11-053 Ef. 711111) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 Select a Misc Bldg/Structure or Element of a Building Suppl. PC Fee: E) Reg. 0 OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee -0 Reg. 0 OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 on Acoustical Fee: 0 Yes 0 No $0.00 0 Work Without Permit? 0 Yes E) No $0.00 Planning Hee: $0.00 Select a Non -Residential Building or Structure Q 0 Strony- Motion Fee: $0.00 0 # $170.00 Alternate Materials and Methods IALTMAT Bldy, Stds Commission Fee: $0.00 SUBTOTALS: $0.00 $170.00 TOTAL FEE: $170.00 Revised: 07/04/2011 CITY OF CUPERTINO 9%7 FEE ESTIMATOR - BUILDING DIVISION NOTE: These fees are based on the nreliminary information available and are only an estimate. Contact the Dent for addn'l info. FEE ITEMS (Fee Resolution 09-051 E '. 7/1/10) ADDRESS: 20902 dunbar dr. DATE: 05/23/2011 REVIEWED BY: bobs. APN: BP#: *VALUATION: $600 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex USE: Suppl. PC Fee: 0 Reg. 0 OT PENTAMATION PERMIT TYPE: WORK revise foundation/wall at garage and laundry local walls at bathroom furnace closet floor sa ce revise SCOPE vent, crawl space floor area. NOTE: These fees are based on the nreliminary information available and are only an estimate. Contact the Dent for addn'l info. FEE ITEMS (Fee Resolution 09-051 E '. 7/1/10) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 Select a Misc Bldg/Structure or Element of a Building Suppl. PC Fee: 0 Reg. 0 OT 0.0 hs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Feer Reg. 0 OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Acoustical Fee: Q Yes (F) No $0.00 Q 0 Work Without Permit? 0 Yes Q No $0.00 Planning $0.00 Select a Non -Residential Building or Structure E)p 0 i Strong- Motion Fee: IBSEISMICR $0.50 1 # $760.00 Revision 1REVSFDwL SFDWL Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: 1 $1.50 $760.00 TOTAL FEE: 1 $761.50 Revised: 04/29/2011 CUPERTINO OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building (a)cupertino.org Dear Property Owner(s): An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified at: SITE ADDRESS V2_ r APN 3z(,- Z(,- 30 - f �l l B o ll (Doy OWNER NAM OWNER ADDESS ��: Rt h 6 . sgnLb06/ A, CA DESCRIPTION OF WORK: /VGw %On We are providing you with an Owner -Builder Acknowledgment and Information Verification Form to make you aware of your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner -Builder. We will not issue a building permit until you have read, initialed your understanding of each provision, signed, and returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION (DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information.) •9 L 1. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner - Builder" building permit that erroneously implies that the property owner is providing his or her own labor and material personally. I, as an Owner -Builder, may be held liable and subject to serious financial risk for any injuries sustained by an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers on my property. AL2. 1 understand building permits are not required to be signed by property owners unless they are responsible for the construction and are not hiring a licensed Contractor to assume this responsibility. 4C 3. 1 understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. ��. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. 225. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer" under state and federal law. ILL 6. 1 understand if I am considered an "employer" under state and federal law, I must register with the state and federal government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject me to serious financial risk. 'L't-7. 1 understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is performed under contract with a licensed general building Contractor. 7L 8. 1 understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for any financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the workmanship or materials. OwnerBuilderForin 2010.doc revised 04/14/10 1 1(- 9. 1 understand I may obtain more information regarding my obligations as an "employer" from the Internal Revenue Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www.Gslb.ca.gov for more information about licensed contractors. '4"-10. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the party legally and financially responsible for proposed construction activity at the site address listed above. 11L 11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner -Builders as well as employers. /IL-12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If you contract with someone who does not have a license, the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or employee of that individual or firm is injured while working on your property, you may be held liable for damages. If you obtain a permit as Owner -Builder and wish to hire Contractors, you will be responsible for verifying whether or not those Contractors are properly licensed and the status of their workers' compensation insurance coverage. CONSTRUCTION LENDING AGENCY (DIRECTIONS: Please complete the following construction lending agency information.) hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec 3097 Civ.) Lender Name: Lender Address: Before a building permit can be issued, this form must be completed and signed by the property owner and returned to the agency responsible for issuing the permit. Note: A copy of the property owner's driver's license, form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's sin ure. Property Owner's Signature: Date: --------------------------------------------------------------------------------------------------------------------------------------------- (NOTE: The following Authorization Form is required to be completed by the property owner only when designating an agent of the property owner to apply for a construction permit for the Owner -Builder). AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize the following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an Owner -Builder Permit for my project. Scope of Construction Project (or Description of Work): Project Location or Address: Name of Authorized Agent: Address of Authorized Agent: Tel No declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above information and certify its accuracy. Note: A copy of the property owner's driver's license, form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's signature. Property Owner's Signature: Date: OwnerBuilderForni 2010. doc revised 04/14/10 CITY OF CUPERTINO FM -7 FEE ESTIMATOR — BUILDING DIVISION 9=1 M11- ADDRESS: 20902 dunbar dr. DATE: REVIEWED BY: PC FEE ID APN: BP#: `VALUATION: 1$812,800 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: New Construction PRIMARY SFD or Duplex USE: F�Z.OUfi ah'I�::�i: PENTAMATION 1 R3SFDW PERMIT TYPE: WORK Elec. Per?nit Fee. SCOPE 0"bur Nten h [n'Ll OCCUPANCY TYPE: TYPE OF CONSTR. FLR AREA s.f. PC FEES PC FEE ID BP FEES BP FEE ID R-3 (Custom) II-B,111-B,IV,V-B 4,311 $2,924.36 1R3PLNCK $3,303.72 1R3INSP Elec. Per?nit Fee. Other Aleck. Insp. 0"bur Nten h [n'Ll 0.0 01her I,ICC. Insp, Li Akeh. Insp. Free: Plumb. lnsp. l -r: PME Unit Fee: EI(,(. In,pn Fce: PME Permit Fee: $0.00 Constr. Tax: IBCONSTAXR 1 bla S $558.42 Acoustical Fee: © Yes (E) No $0.00 Q Work Without Permit? 0 Yes 0 No $0.00 TOTALS: 4,311 $2,924.36 Travel Documentation Fee: 1TRAVDOC $3,303.72 Strong, Motion Fee: IBSEISMICR 30 FEE QTY/FEE MISC ITEMS Plan Check Fee: $2,924.36 200 # Electrical $402.00 IBREMRECEP Recep/Switch/Outlets Xfech. Plan C&ck 1'lzimh. Nn)C "/1,t, E, 1 hrs Elec`. Plan Chcck : -11 /1. Pennil h"e�r�: 1'Lrrnh. Tarr fl P"C: Elec. Per?nit Fee. Other Aleck. Insp. 0"bur Nten h [n'Ll 0.0 01her I,ICC. Insp, Li Akeh. Insp. Free: Plumb. lnsp. l -r: PME Unit Fee: EI(,(. In,pn Fce: NOTE. These fees are based on the nreliminary information available and are onlv an estimate. Contact the Dent for addn'1 info. FEE ITEMS (Fee Resolution 09-05I E . 7/UID) FEE QTY/FEE MISC ITEMS Plan Check Fee: $2,924.36 200 # Electrical $402.00 IBREMRECEP Recep/Switch/Outlets Suppl. PC Fee: 0 Reg. 0 OT 0.0 1 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $3,303.72 Suppl. Insp. Fee{' Reg. CI OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Constr. Tax: IBCONSTAXR 1 bla S $558.42 Acoustical Fee: © Yes (E) No $0.00 Q Work Without Permit? 0 Yes 0 No $0.00 Planning Fee: PLLONGRNGR $560.43 Select a Non -Residential 0 Building or Structure Travel Documentation Fee: 1TRAVDOC $42.00 Strong, Motion Fee: IBSEISMICR $81.28 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $33.00 $7 503.21 402.00 $7,905.21 Revised: 11/08/2010 RECORDING REQUESTED BY: Chicago Title Company Escrow No.: 1498417380. Locate No.: CACT17743-7743-2984-0048417380 Title No.: 10 -98417380 -RP When Recorded Mail Document and Tax Statement To: Hu Herbert Chao & Vivian Wei -Wen Chao 11552 White Cliffs Ave., Las Vegas, NV 89135 APN: 326-30-141 The undersigned grantor(s) declare(s) DOCUMENT: 2D695090 REGINA ALCOMENDRAS SANTA CLARA COUNTY RECORDER Recorded a. the request of Chicago Title GRANT DEED -ages 2 Fees 18.00 Taxes.. 1193.50 yes. Aµi PAD 1211.50 RDE " 008 4/30/2010 8:00 AM LII Jirhg WodTatik/ Declararfl�Documentary transfer tax is $1,193.50 [ x ] computed on full value of property conveyed, or [ ] computed on full value less value of liens or encumbrances remaining at time of sale, [ ] Unincorporated Area City of -Cu pI FOR A VALUABLE CONSIDERATION, receipt of which is hereby acknowledged, Jung Woo Tahk and Myung Soon Tahk, husband and wife hereby GRANT(S) to �- Hu Herbert Chao &Vivian Wei -Wen Chao, trustees of The Hu Herbert Chao &Vivian Wei -Wen Chao Living Trust, dated October 11, 2005, as to an undivided 50% Interest and Theodore gist Tuan Chao, a single man, as to an undivided 30% interest, all as Tenants in Common Ming Shivan the following described real property in the City of Cit�eftWo, County of Santa Clara, State of California: (% SEE EXHIBIT "A"ATTACHED HERETO AND MADE A PART HEREOF q) DATED: April 15, 2010 State of California County of ung W Tahk On �/ fi - before me, Notary Public (here in rt name 6nd title dt the officer), personally appeared ng on k Jung Woo TAhk and Myung Soon Tahk, who proved to meon the of satisfactory evidence to be the person(s) whose names) i ares sa*anthat he within instrument and ack ged to me tha a/sheecuted the same his/he their thorized capacity(fes), by his/her eir signatu on the instrument the person(s), or the entity up�i AGNES YEE behalf of which the person(s) acted, executed the Instrument. CoMu.# 1879074 7 xowrr PUBLIC -c MAHLA I certify under PENALTY OF PERJURY under the laws of the State of SMTA 0."R" ca'"" Yr Corot Ocn. F[e. 2.20te '" California that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature (Seal) MAIL TAX STATEMENTS AS DIRECTED ABOVE _ FD -213 (Rev 12/07) GRANT DEED (grant)(06-09) INSTALLATION CERTIFICATE CF -6R -ENV -01 Envelope — Insulation; Roofing; Fenestration (Page i of 3) Site Address: 0 / Enforcement Agency: Permit Number: t[21�)ttr 'JY. Cklr..fk., Gil loll aolt7 If more than one person has responsibility for installation of the items on this certificate, each person shall prepare and sign a certificate applicable to the portion of constructionfor which they are responsible; alternatively, the person with chief responsibilit •ontstrttctiowt shall prepare and sign this certificate for the entire construction. All applicable Mandalory Measures with check bores uire to be c t ed to ensure the nnandatory measures have been mel. Description of insulation t 1. RAISED FLOOR Material: gA Ti Brand Name: d�» /ay✓' /�� Thickness (inches): Thermal Resistance (R-Va e): a l 0 § 150(d): Minimum R-13 insulation in raised wood -frame Floor or equivalent U -factor. 2. SLAB FLOOR/PERiMETER Material: Brand Name: Thickness (inches): Thermal Resistance (R -Value): Perimeter insulation Depth (inches): ❑ § 150(1): Water absorption rate for the insulation material alone without facings is no greater than 0.3%; water vapor permeance rate is no greater than 2.0 perm/inch and shall be protected from physical damage and UV light deterioration. 3. EXTERIOR WALL a. insulation Type (e.x. Batt, Loose Fill, Spray Foam) SPIOC-IR (SpuAy v71 b.. Insulation Type (e.x. Batt, Loose Fill, Spray Foam) Brand: 701.p- 4A],-ily Y%der a. Thermal Resistance (R -Value): :2.3 b. Thermal Resistance (R -Value): Spray/Loose fill) installed Actual Thickness Spray/Loose fill) (inches): Contractor's min installed weight/ftz Manufacturer's installed weight per square foot to achieve Thermal Resistance (R -Value) 6-§1-5 (c): Min, R- 13 insulation in wood -frame wall or equivalent U -factor. Exterior Foam She�g-(rigid Insulation) Material: Brand Name: Thickness (inches) : I Thermal Resistance (R -Value) 4. FOUNDATION WALL J' Material: Cbsed Com!/ Foal - SPK1 o/V Brand Name: �vx b0i✓�( Thickness (inches): ;,, Y t' Thermal Resistance (R -Value): 1 / 5. CEILING Batt or Blanket Type: t f Brand Name: °Gry s - M"L/,"/c Loose Fill Type: Thermal Resistance (R -Value): Spray Foam Type: Brand Name: Installed Actual Thickness (inches): Contractor's min installed weight/ftz Manufacturer's installed weight per square foot to achieve Thermal Resistance (R -Value): fib §150(a): Minimum R-19 insulation in wood -frame ceiling or equivalent U -factor. 6. ATTIC ROOF INSULATION AND/OR ATTIC RADIANT BARRIER Material: Brand Name: t' Material: Brand Name: Thickness (inches): Thermal Resistance (R -Value): LI § i 18(a): insulation installed meets Standards for insulating Material. Of § 150(8): Mandatory Vapor barrier installed in Climate Zones 14 or 16. n Ib lb 2008 Residential Compliance Forms August 2009 INSTALLATION CERTIFICATE CF -6R -ENV -01 Envelope — Insulation; Roofing; Fenestration (Page 2 of 3) Site Address: .� Enforcement Agency: Permit Number: 2 v yob Dvn�ial I)r. C� rat /�r.✓, CA ?fOlq- 1011 00 �-7 Description of R ofing Products CRRC Product iD Manufacturer Manufacturer/Brand Name GROUP LIKE RODUCTS) Product Roof Roof Product Initial Solar Aged Solar Thermal Numbcr' Information Brand/Model Type Arca Sloe wci ht 2 Rcticctancc Reflectance' Emittancc 4.,e Saud Leria:u7a•� �res:�la. i -n Sl,�� ropy act 0,21 1,3, 4"e Weft 3 M:I d W-1-0 0.19 SL: r s /l Y 7 $9 []3 4 15, zy a. �) / ► y 116 1' 35o. ❑3 47 0,27 1 Y ❑3 cPoor (��Idwi.) <�, 3 1. The CRRC Product ID Number can be obtained from the Cool Roof Raling Council's Rated Product Directory at wtv. coolroofs. org/products/search. php 2. The weight in lbs per square feet of the roofing product being installed. 3. Check box if the Aged Reflectance is a calculated value using the equation below, footnote 4. 4. /f the aged reflectance is not available in the Cool Roof Raling Council's Rated Product Directory then use the initial reflectance value from the directory and use the equation (0.2+0.7( i„ i,i„ t — 0.2) to obtain a calculated aged value. ✓OCHECK APPLICABLE BOX BELOW IF EXEMPT FROM THE ROOFING PRODUCT "COOL ROOF" REQUIREMENT.• ❑ The roof area covered by building integrated photovoltaic panels and building integrated solar thermal panels are exempt from the above Cool Roof criteria. ❑ Roof constructions that have thermal mass over the roof membrane with a weight of at least 25 lb/ft2 is exempted from the above Cool Roof criteria. To apply Liquid Field Applied Coatings, the coating must be applied with a minimum dry mil thickness of 20 mils across the entire roofsurface and meet mininutm erformance requirements listed in '118 i 3 and Table 118-C. Select the applicable coating ❑ Aluminum -Pigmented Asphalt RoofCoating ❑ Cement -Based Roof Coating ❑ Other' ✓ ❑ CRRC-1 Label Attached to CF -6R (Note i no CRRC-1 label is available, this compliance melhod cannot be used and another method is re wired to meet compliance). FENESTRATION/GLAZING Item Manufacturer/Brand Name GROUP LIKE RODUCTS) Product U- factor' Product SHGC' b of Panes NFRC Certified'" Total Quantity of Like Product (Optional) T, LL4 Area W Add. Exterior Shading Dev. or Overhang Comments/ Location/ Special Features I 1K Iltars' 1%l"N. o J iF-hu' ac)E'' 1 (3.29 D, i{ y S J4� , . 3 �, ti 4.,e Saud 2 Mtl aro Wild— 0.3/vh 0,21 1,3, 4"e Weft 3 M:I d W-1-0 0.19 0.11 s /l Y 7 $9 1` 31 4 15, zy a. �) / ► y 116 1' 35o. 47 0,27 1 Y 6 cPoor (��Idwi.) <�, 3 ,o..3 a N 7. t c'o, it s. /. Use values from a fenestration product's NFRC Certified Label. For fenestration products without an NFRC label, use the default values from Section/ /6, Tulle 116-A and 116-B of the 2008 Energy Efficiency Standards. 2. NFRC Label Certi icates shall not be removed until the building inspector has veri red the eJTciencv. Enter Yes or No. ld § 116(x)1: Doors and windows between conditioned and unconditioned spaces designed to limit air leakage. if § l 16(a)2 and 3: Actual fenestration products installed are equivalent to or have a lower U -factor and/or a lower SHGC than that specified on the Certificate of Compliance (Form CF -I R). Rf § 1 16(a)4: Fenestration products (except field -fabricated windows) have a label listing the certified U -Factor, certified Solar Heat Gain Coefficient (SHGC), and infiltration that meets the requirements of § 10-1 1 1(a) d§ 117: Exterior doors and windows weather-stripped; all joints and penetrations caulked and sealed. 2008 Residential Compliance Forms August 2009 INSTALLATION CERTIFICATE CF -6R -ENV -01 Envelope — Insulation; Roofing; Fenestration (Page 3 of 3) Site Address: Enforcement Agency: Permit Number/: �2G 01 Ottnbal- on C o•fio, CA T,000 -lot / oo(L Z DECLARATION STATEMENT • 1 certify under penalty of perjury, under the laws of the State of California, the information provided on this form is true and correct. • I am eligible under Division 3 of the Business and Professions Code to accept responsibility for construction, or an authorized representative of the person responsible for construction (responsible person). • I certify that the installed features, materials, components, or manufactured devices identified on this certificate (the installation) conforms to all applicable codes and regulations, and the installation is consistent with the plans and specifications approved by the enforcement agency. • 1 reviewed a copy of the Certificate of Compliance (CF- I R) form approved by the enforcement agency that identifies the specific requirements for the installation. I certify that the requirements detailed on the CF -I R that apply to the installation have been met. • 1 will ensure that a completed, signed copy of this Installation Certificate shall be posted, or made available with the building permit(s) issued for the building, and made available to the enforcement agency for all applicable inspections. I understand that a signed copy of this Installation Certificate is required to be included with the documentation the builder provides to the building owner at occupancy. Company Name: (Installing Subcontractor or General Contractor or Builder/Owner) Nu CNRO Coo-1CY) Responsible Person's Name: H, G� ati Responsible Person's Signature: µ a ---c CSLB License: Date Signed: Position With Company (Title): W3- Z,0 17— w7f eV. 2008 Residential Compliance Forms August 2009 I INSTALLATION CERTIFICATE CF -6R -LTG -01 Residential Lighting Pa eI of3) Site Address: Enforcement Agency: Permit Number: �0 Pu.bar Or. , Cu Pnf�ro; CA 1611liu[f 7 1. Kitchen Lighting Dnec nmiert inchrrle kitchen hAtinO Yes. complete section 1 ❑ No, go on to section 2 0 Yes ' 150(k)3: The wattage of permanently installed luminaires (lighting fixtures) has been determined asspecified by § 130(d). ❑ Yes En No §150(k)3: In the kitchen, are there electrical boxes finished with a blank cover or where no electrical equipment has been installed. and where the electrical box can be used for a luminaire or a surface mounted ceiling fan? If yes, the following row must also be yes: ❑ Yes IO NA Wattage has been calculated as 180 watts of low efficacy lighting er blank electrical box. §I50(k)8 Kitchen Lighting must comply with either method (a), (b), or (c) below: (a) All high efficacy luminaires ❑ Yes, complies because only high efficacy luminaires have been installed in the kitchen. No, complies with method (b) or c). (b) > 50% watts used by high efficacy luminaires Eil Yes, complies because at least 50%of the installed watts are from permanently installed high efficacy luminaires as demonstrated in the table below: Total A >_ Total B. ❑ No. complies with method (a) or (c). Fill out the following table if complying with either method (b) or (c). Table (b) Luminaire Type Efficacy High Low Watts x Quantity High Efficacy Watts or Low Efficacy Watts 411L G-ka 1:14 o ❑ 13 x 6 7 8 or ❑ ❑ x = or ❑ ❑ x = or Complies with method (b) if A > B Total: A: ZZ06 >_ B: / S'0 (c) Additional Kitchen Low Efficacy Lighting ❑ Yes, complies because the kitchen lighting qualifies for additional low efficacy lighting and as demonstrated in table in (b) (above) and the table in (c) (below) that ( A + C) >_ B ❑ No. complies with method (a) or (b). Additional kitchen low efficacy lighting is available only if all of the following are true: ❑ Yes. All low efficacy luminaires in the kitchen are controlled by a vacancy sensor Dimmer energy management control system (EMCS) or a multi -scene programmable control system. ❑ Yes. Permanently installed luminaires in garages laundry rooms closets greater than 70 square feet and utility rooms are high efficacy luminaires AND are controlled by a vacancy sensor. Table (cl From the Table in (b) Use 50 W for dwelling units:5 2,500 ft - Use 100 W for dwelling units > 2,500 ft-' Add Yes/No ? A B C A+ C Is (A+Q > B? 2. Lighting Internal to Cabinets Does project includes lighting internal to cabinets? ❑ Yes. complete section 2 K No, go on to section 3 ❑ Yes. § I50(k)9: Permanently installed lighting internal to cabinets uses:5 20 watts of power per linear foot of illuminated cabinet. 2008 Residemial Compliance Fornrs August 2009 INSTALLATION CERTIFICATE CF -6R -LTG -01 Residential Lighting (Page 2 of 3 Site Address:L Enforcement Agency: PeNi. rmit Nmber: .2o?o 1 OiAi- for ur;ve , L�. E. /ih�, C,1 I / o l/ oo �-% 3. Installed Devices and Components Have Been Certified to the Energy Commission Does the project include any of the devices or components listed below? M(Yes, complete section 3 ❑ No, go on to section 4 [a Yes §1 19 and § 150(k)7(F): Any of the following devices and components which have been installed have been certified to the Energy Commission according to the applicable provisions of §1 19: All LED lighting systems that are classified as high efficacy, ballasts used in recessed luminaires, vacancy sensors (automatic off/manual on occupant sensors), dimmers, track lighting integral current limiters, and outdoor motion sensors. 4. Lighting Controls Comnlete section 4 Yes ❑ NA § 150(k)7A: Permanently installed low efficacy luminaires are controlled by switches separate from those controlling high efficacy luminaires. ❑ Yes GY NA § 150(k)7B: Exhaust fans with integral lighting systems are switched separately from lighting systems, OR have a lighting system that can be manually turned on and off while allowing the fan to continue to operate for an extended period of time. IoM Yes ❑ NA §150(k)7C: All permanently installed luminaires are switched with readily accessible controls that permit the luminaires to be manually switched on and off. Yes ❑ NA §150(k)7D: All lighting controls have been installed in accordance with the manufacturer's instructions. Yes ❑ NA § 150(k)7E: All lighting circuits that are controlled by more than one switch, where a dimmer or vacancy sensor has been installed to comply with § 150(k), no controls bypass the dimmer or vacancy sensor functions. 5. Luminaires (Lighting Fixtures) Does the nmiect include the installation of anv luminaire- (indoor or cnddnor19 Yes, complete section 5 ❑ No, go on to section 6 LJ Yes, high efficacy luminaire classification has been determined according to § 150(k)1, and low efficacy luminaire classification has been determined according to § I50(k)2. Yes ❑ NA § I50(kA Fluorescent lamps rated 13 watts or greater have an electronic ballasts having an output frequency no less than 20 kHz. Yes ❑ NA § I50(k)5: Permanently installed night lights, and night lights integral to permanently installed luminaires or exhaust fans, contain only high efficacy lamps meeting the minimum efficacies contained in Table 150-C and do not contain a line -voltage socket or line voltage lamp holder, OR the night light is rated to consume no more than 5 watts of power and does not contain a medium screw -base socket. 09 Yes ❑ NA §150(k)6: Lighting integral to exhaust fans, in rooms other than kitchens, meet the applicable requirements of §150(k), ❑ Yes 11 NA Any electrical box finished with a blank cover or where no electrical equipment has been installed, and where the electrical box can be used for a luminaire or a surface mounted ceiling fan, has been treated as low efficacy luminaires for compliance with § 150(k). Does the project include any luminaires that are recessed into insulated ceilings? Yes, complete the rest of section 5 ❑ No, go on to section 6 Yes, § 150(k)12: Luminaires that are recessed into insulated ceilings meet all of the following conditions: Yes, are listed, as defined in §101, for zero clearance insulation contact (IC) by UL or other nationally recognized testing/rating laboratory, and d Yes, have labels that certify the luminaires are airtight with air leakage less than 2.0 CFM at 75 Pascals when tested in accordance with ASTM E283 (Exhaust fan housings are not required to be certified airtight), and IBJ Yes, are sealed with a gasket or caulk between luminaire housings and the ceiling, and all air leak paths between conditioned and unconditioned spaces have been sealed with a gasket or caulk. (including all exhaust fan housings), and Yes, allows ballast maintenance and replacement to be readily accessible to building occupants from below the ceiling without requiring the cutting of holes in the ceiling. 6. Indoor Lighting (any indoor room that is not a kitchen) Does the project mcluoe permanently Installed luminaires in any room that is not a kitchen'! M Yes, complete section 6 ❑ No, go on to section 7 Yes ❑ NA §150(k)10: Permanently installed luminaires in bathrooms, garages, laundry rooms, closets> 70 ft 2, and utility rooms are high efficacy luminaires OR are controlled by a vacancy sensor. Yes ❑ NA § 150(k) 11: Permanently installed luminaires located in rooms or areas other than in kitchens, bathrooms, garages, laundry rooms, closets, and utility rooms are high efficacy luminaires, OR are controlled by a dimmer switch OR are controlled by a vacancy sensor. 2008 Residential Compliance Forms August 2009 INSTALLATION CERTIFICATE CF -6R -LTG -01 Residential Lighting (Page 3 of 3 Site Address:' Enforcement Agency: Permit Number: %7. ,A ?�, 7. Outdoor Lighting Does the project include any permanently installed outdoor lighting? 0 Yes, complete section 7 ❑ No, go on to section 8 83,Yes ❑ NA §150(k)13: Luminaires providing outdoor lighting, including outdoor lighting for private patios on low-rise residential buildings e 6 Res on's S' azure: with four or more dwelling units, entrances, balconies. and porches, and which are permanently mounted to a residential building or to other buildings on the same lot are high efficacy luminaires OR are controlled by a manual on/off switch, plus a Date Signed: 7 r�C 7—/ motion sensor not having an override or bypass switch that disables the motion sensor, plus one of the following three additional control methods: a. A photocontrol that does not have an override or bypass switch that disables the photocontrol; or b. An astronomical time clock not having an override or bypass switch that disables the astronomical time clock; or C. Energy management controls systems (FMCS) not having an override or bypass switch that allows the luminaire to be always on. Yes ❑ NA Exception 2: Low efficacy outdoor luminaires used to comply with Exception I to § 150(k)13 are controlled by an override switch which temporarily bypasses the motion sensing function, and the motion sensor is automatically reactivated within six hours. The luminaire is controlled by a photocontrol, astronomical time clock, or EMCS as required by Exception I to §I50(k)13. ❑ Yes 5 NA Exception 3: There are permanently installed luminaires in or around swimming pools, water features, or other locations subject to Article 680 of the California Electric Code which do not need to be high efficacy luminaires. ❑ Yes NA §150(k)14: Internally illuminated address signs comply with §148, OR do not contain a screw -base socket and consume no more than 5 watts of power as determined according to § 130(d). ❑ Yes IWNA §150(k)15 Lighting for parking lots and carports with a total of 8 or more vehicles per site have lighting that complies with § 130,132, 134, and 147. Lighting for parking garages for 8 or more vehicles comply with § 130, 131, 134, and 146. If yes, the Nonresidential compliance forms must be submitted 8. Common areas of low-rise residential buildings Does the project include the installation of any luminaires in common areas of low-rise residential buildings? ❑ Yes, complete section 8 06 No, go on to section 9 ❑ Yes, § 150(k)16: Permanently installed lighting in the enclosed, non -dwelling spaces of low-rise residential buildings with four or more dwelling units shall be high efficacy luminaires OR are controlled by occupant sensor(s) certified to comply with §1 19(d). DECLARATION STATEMENT • 1 certify under penalty of perjury, under the laws of the State of California, the information provided on this form is true and correct. • 1 am eligible under Division 3 of the Business and Professions Code to accept responsibility for construction, or an authorized representative of the person responsible for construction (responsible person). • 1 certify that the installed features, materials, components, or manufactured devices identified on this certificate (the installation) conforms to all applicable codes and regulations, and the installation is consistent with the plans and specifications approved by the enforcement agency. • I reviewed a copy of the Certificate of Compliance (CF -I R) form approved by the enforcement agency that identifies the specific requirements for the installation. I certify that the requirements detailed on the CF -I R that apply to the installation have been met. • 1 will ensure that a completed, signed copy of this Installation Certificate shall be posted, or made available with the building permit(s) issued for the building, and made available to the enforcement agency for all applicable inspections. 1 understand that a signed copy of this Installation Certificate is required to be included with the documentation the builder provides to the building owner at occupancy. Company Name: (Installing Subcontractor or General Contractor or Builder/Owner) tJ Unt-S Et-r-cft- t-C— ame: Responsib a Perso 's Nle e 6 Res on's S' azure: CS/L�B License: (C / Date Signed: 7 r�C 7—/ Po si ' -n—With Compan (Title): 2008 Residential Compliance Forms August 2009 • 'a INSTALLATION CERTIFICATE CF-6R-MECH-01 Domestic Hot Water (Page I of 2 Site Address: Enforcement Agency: Permit Number: ao yo 1 pmt lar Dy. Ck e�t�.�. CA �91 /6V 4- 7 WATER HEATING SYSTEMS: Heater Type CEC Certified Mfr Name & Model Number Distribution Type (Std, Paint -of- Use, etc) If Recirculation, Control Type # of Identical Systems Rated Input (kW or Btu/hr) Tank Volume (gallons) Efficiency (EF, RE)t Standby Loss (%)t (aa %2nPels 42 v wet is,loa aro 7t SG x.46 Note 1: For small gas storage (rated input less that or equal to 75, 000 Btu/hr), electric resistance and heat pump water heaters, list Energy Factor (EF). For large gas storage water heaters (rated input of greater than 75,000 Btu/1rr), list Recovery Efficiency (RE), Thermal Ef ciency, Standbv Loss and Rated Input. For instantaneous gas water heaters, list the Thermal Efficiency and Rated Input. 2. Mandatory Measures TO COMPLY - ALL BOXES MUST BE CHECKED © § 1 10-§ 113: Water heaters, showerhead and faucets are certified by the California Energy Commission. § 1506): Water System Pipe and Tank Insulation. And Cooling Line Insulation I . Storage tank insulation A. Storage gas water heaters rated with an Energy Factor no greater than the federal minimal standard are externally wrapped with insulation having an installed thermal resistance of R-12 or greater; and B. Unfired storage tanks or other indirect hot water tanks have R-12 external insulation or R-16 internal insulation where the internal insulation R -value is indicated on the exterior of the tank. 2. Water piping and cooling system line insulation thickness and conductivity 121 First 5 feet of hot and cold water pipes closest to water heater tank, non -recirculating systems, and entire length of recirculating sections of hot water pipes are insulated per Standards Table 150-13; and E3 Pipe insulation for steam hydropic heating systems or hot water systems > 15 psi, meets the requirements of Standards Table 123-A. ED Insulation is protected from damage, including that due to sunlight, moisture, equipment maintenance, and wind. ® § 151 M813: If indicated on the CF- I R, all hot water piping that runs from the hot water source to the kitchen fixtures is insulated per Standards Table 150-13. 2008 Residential Compliance Fornrs August 2009 M INSTALLATION CERTIFICATE CF-611-MECH-01 Domestic Hot Water (Page 2 of 2 Site Address: Enforcement Agency: Permit Number: ------------- 3. Central Water Heating in Buildings with Multiple Dwelling Units (required for prescriptive) TO COMPLY - ALL BOXES MUST BE CHECKED ❑ All hot water piping in main circulating loop is insulated to requirements of § 1500) ❑ Central hot water systems serving six or fewer dwelling units which have (1) less than 25' of distribution piping outdoors; (2) zero distribution piping underground; (3) no recirculation pump; and (4) insulation on distribution piping that meets the requirements of Section 1500) ❑ Central hot water systems serving more than 6 dwelling units - presence of either a time control or a time/temperature control DECLARATION STATEMENT • I certify under penalty of perjury, under the laws of the State of California, the information provided on this form is true and correct. • 1 am eligible under Division 3 of the Business and Professions Code to accept responsibility for construction, or an authorized representative of the person responsible for construction (responsible person). 1 certify that the installed features, materials, components, or manufactured devices identified on this certificate (the installation) conforms to all applicable codes and regulations, and the installation is consistent with the plans and specifications approved by the enforcement agency. • 1 reviewed a copy of the Certificate of Compliance (CF -I R) form approved by the enforcement agency that identifies the specific requirements for the installation. I certify that the requirements detailed on the CF -I R that apply to the installation have been met. • 1 will ensure that a completed, signed copy of this Installation Certificate shall be posted, or made available with the building permit(s) issued for the building, and made available to the enforcement agency for all applicable inspections. I understand that a signed copy of this Installation Certificate is required to be included with the documentation the builder provides to the building owner at occupancy. Company Name: (Installing Subcontractor or General Contractor or Builder/Owner) Nti CI -IAO (��✓�rer J Responsible Person's Name: Responsible Person's Signature: Hu &PAv _dtr. i-�- CSLB License: Date Signed: Position With Company (Title): y�3o/za /Z 0,V-petr 2008 Residential Compliance Forms August 2009 Site Addteat Space Conditloning Sydems Hea tgBgaiment se areemantAteu>r I Permit Number: C00,1109 Egs*xu rt MANN 'MR Mi... P F10r .�1'' e ' ' ®ii1�17� rM C00,1109 Egs*xu rt 1. {f project is new construcdon, see Footnotes to Standards Table 151-B and Table 151-0 for duct cdit alternative ooegplianee. 2. APJ Rn fwrenoe Number can be fowdd by entering the equipment model number at Agp:11www ortdirectory.ag/artlac phpti 3. !.natal gWdency on thts page must be gteatw that or equal (Z) to the value shown on the CF -1 R form. 4. Whet CF -JR is rrfer>esce (t is also applkable to the CF -111; CF -1R -AA or CF -IR -ALT ALL BOXES MUST BE CHECKED TO BE A VALID FORM )9$1 l0-$113: HVAC equipment is certified by the California Energy Commission. 150(h): Heating and/or cooling loads calculated in accordance with ASHRAE, SMACNA. or ACOA. 1 SO(i): Setback Thermostat on all applicable heating and/or cooling systems meet the requirements of $112(c). A l M)2: Pipe insulation fbrcooling system re8'igaent suction, chilled water and brine linea meets minimum requitemeuts of Table 150-B and includes a vapor retardant or is enclosed entirely in conditioned space. 208 Raidemdal Compliance Forms December 2008 MANN 'MR 1. {f project is new construcdon, see Footnotes to Standards Table 151-B and Table 151-0 for duct cdit alternative ooegplianee. 2. APJ Rn fwrenoe Number can be fowdd by entering the equipment model number at Agp:11www ortdirectory.ag/artlac phpti 3. !.natal gWdency on thts page must be gteatw that or equal (Z) to the value shown on the CF -1 R form. 4. Whet CF -JR is rrfer>esce (t is also applkable to the CF -111; CF -1R -AA or CF -IR -ALT ALL BOXES MUST BE CHECKED TO BE A VALID FORM )9$1 l0-$113: HVAC equipment is certified by the California Energy Commission. 150(h): Heating and/or cooling loads calculated in accordance with ASHRAE, SMACNA. or ACOA. 1 SO(i): Setback Thermostat on all applicable heating and/or cooling systems meet the requirements of $112(c). A l M)2: Pipe insulation fbrcooling system re8'igaent suction, chilled water and brine linea meets minimum requitemeuts of Table 150-B and includes a vapor retardant or is enclosed entirely in conditioned space. 208 Raidemdal Compliance Forms December 2008 Ducts and Fans 4 150(m): Duct and Faun 1. All air-disiribudon system ducts and plenums installed, sealed and insulated to meet the requirements of CMC Sections 601, 602, 603, 604, 605 and Standard 6-5; supply -air and return -air ducts and plenums are insulated to a minimum installed level of R4.2 or enclosed entirely in conditioned space. Openings shall be sealed with mastic, tape or other duct -closure system that sheet the applicable requieemants of UL 191, UL III1 A, or UL 181 B or aerosol sealant that meets the requirments of UL 723. If masdc or tape Is used to seal openings greater than 114 inch, the sn"on of mastic and either mesh or tape shall be used; and 1. Building cavities, support platforms for air handlers, and plenums defined or constructed with materials other thea sealed sheet metal, duct board or flexible duct shall not be used for conveying conditioned air. Building cavities end support phdbms may contain duct. Ducts installed in cavities and support platfbrms ahaU not be compressed to cause reductions In the a n-sxdonal area of the ducts. 21). Joints and seams of dud systems and their components shall not be sealed with cloth back rubber adhesive duct tepee unless such tape is used In eornbinadon with nmatic and draw bands. A7. Exhaust fan syateas have back draft or automatic dampers. `w B. Gravity ventilating systems serving conditioned space have either automatic or readily accessible, manually operated dampers. 9. 9. Protection of Insulation. Insulation shall be prowted Som damage. including that due to sunlight, moisture. equipment mainte ism and wind. Cellular foam fnauladon shall be protected as above or painted with a coating that is water retardant and provides shielding Som solar radiation drat can cause degradation of the material. 10. Flexible duct cannot have porous inner corns. DECLARATION STATEMENT • I cw* under penalty of perjury, under the Inn of the State of Calitornla. the laformation provided on this form is true and coned. • 1 am eligible under Division 3 of site Button and Pmft*m Code to accept responsibility fbr constnrction, or an authorized represeamdva of dw person dile far oomou don (responsible perste). • I cord$ that the installed fbatures, matetials, components, or mamdfhctined devices Mcn6fwd on this ate (the installation) cwforzss to all applicable codes and regulations, and the installation Is consistent with the plans and spedfizbm approved by the enforoemeat agency. • 1 mviewed a copy of the Certitiame ofComphance (CF -IR) fornt approved by the saftowmW agawy drat idcaWias the specific regthtre— for sire ioemlhtdoo. i certify that the requirement detailed on the CF -IR that apply to the installation limb= met. • 1 wM emcee that a completed, signed eop9 of this Iuhfladen Cwddmte d aU be posted, or made avWabie with the buUftg pw mWe) Issued tar the brag, and made nxUable to tabs anh eenwo agency for s0 appUcaMe inspecdom I andsrstad that a s4ped espy of this Ins4tWBOa Certlaeate Is required to be Included with the doewnestatlen the builder provides to the boUdiq owner at occupancy 2008 ReafdauW1 Corapdmme Forums December 2008