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15020088CL CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10095 BRET AVE CONTRACTOR: HORIZON PERMIT NO: 15020088 CONSTRUCTION OWNER'S NAME: HSIAO SUTSEN D AND TSERNG HUAH YEU 35506 ORLEANS DR DATE ISSUED: 06/25/2015 OWNER'S PHONE: 4089730438 NEWARK, CA 94560 PHONE NO: (510) 673-4769 VW LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL License Class Lic. # -+' �' � i CONSTRUCT 2 STORY SFDWL , LIVING AREA (3184SQ FT), ATTACHED GARAGE (473 SQ FT), BALCONY AND PATIO Contractor `r oAfj L` Date 2 1 (498 SQFT) * DETACHED GRANNY UNIT TO REMAIN* 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 Sq. Ft Floor Area: Valuation: $70000 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. APN Number: 37511023.00 Occupancy Type: APPLICANT CERTIFICATION I certify that I have read this application and state•that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED 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 WITHIN 180 DAYS OF PERMIT ISSUANCE OR upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, 180 D S FROM LAST CALLED INSP CTI N. ° costs, and expenses which may accrue against said City in consequence of the 11AU V.� Issued granting of this permit. Additionally, the applicant understands and will comply by: Date: with all non -point sou egulations per the Cupertino Municipal Code, Section 9 18. Signa Date b RE -ROOFS: _ All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. ❑ OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date: the following two reasons: 1, as owner of the property, or my employees with wages as their sole compensation, ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER 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 HAZARDOUS MATERIALS DISCLOSURE construct the project (Sec.7044, Business & Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the I hereby affirm under penalty of perjury one of the following three California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the declarations: I have and will maintain a Certificate of Consent to self -insure for Worker's Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous Compensation, as provided for by Section 3700 of the Labor Code, for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Sections 2 25533, and 25534. Section 3700 of the Labor Code, for the performance of the work for which this Owner —" —Date• 1i permit is issued. or authorized age 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 CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code, I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Address 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, ARCHITECT'S DECLARATION costs, and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section Licensed Professional 9.18. Signature Date CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 B. (408) 777-3228 - FAX (408) 777-3333 - building \� CU ATINO a-cupertino.oLcl NEW CONSTRUCTION D ADDITION El ALTERATION / TI 0 REVISION / DEFERRED ORIGINAL PERMIT # PROJED q6n�f N,, PHOftFY3 ZX09, -//- E-MAIL STREET ADD WS CLr STATE ZIPFAX C ONTACT NAME —LA E-MAIL, Lct)n -4, L RA STREPADDS CITY, STATEZ P El bWNER El mkrNER_BuiLDER ❑ OIAINERAGENT 11 CONTRACTOR El CONTRACTOR AGENT ❑ ARCHITECT —eEIGINEER 11 DEVELOPER E] TENANT F_ CONTRACTOR NAME EN SE NUMBER LICENSE LICENSE TYPE BUS. LIC 4 COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONTE ARCHITE LICENSE NUMBER pp BUS. LIC co E-MAIL ;a FAX i STREET ADDRESS CITY, STATE, ZIP DESCRIPTIO WOR ,,k e_d a U '1r'Q1-7A1 EXISTING USE PROPOSED US TU CONSTR. TYPE 9 STORIES A,,�J i�c. I _1�1 USE TYPE OCC.FT. VALUATION (S) EXISTGNEW AREA FLOOR AREA 7 DEMO AREA /., 1 _!�C) I TOTAL " i t NET AREA (rg ) _.�v -) BATHROOMHEN REMODEL AREA 94CODEJAREA OTHER REN40DEL AREA PORCH AREA DECK AREA TOTAL DECKIPORCI-I AREA GARAGE AREA: ❑AD, /��-v I jTI`ACH 2l A TACH 113. DWELLING UNITS: IS A SECOND UNIT 0 YES SECOND STORY E]YES -BEING ADDED? ONO ADDITION? ❑NO d I.Tw - PRE-APPLICATIONiTS IF YES, PR COPY OF PLANNINGA OVAL LETTER PPNo IS THE BLDG AN E] YES EICHLER HOME ? NO Rm';A yi Fagg; .4,n TOTAL VALUATION: a By my signature below, I certify to each of the following: I am the property owner or authorized afint to act on the prope owner's behalf. I have read this --f—, e. I agree to comply with all applicable local an application and the information I have provided is correct. I have read the Description of Work d verify i is ac m2 ordinances and state laws relating to bui dine construction. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes. /Ir pr ­> / 7,11, ) Signature of Applicant/Agent: - _,< 1-// -5 Date: 0 f 4'a� SUPPLEMEI\TTi"TFORMAOGN�PF-QUIRED New SFD or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building �kp for new building. 1N.'aV RW� a'Q'0,%_ _ OEM pennit _w.. , % R Commercial Bldas:. Provide a completed Hazardous Materials Disclosure PI�M=Tv% V 1 form if any Hazardous Materials are being used as part of this project. M a, -2- M — , .1 Copy of Planning Approval Letter or Meeting with Planning prior to 0— submittal ofBuilding Permit application. 1MIE,- _1_0 B1d,oApp_.:2011.doc revised 06121111 CCTV OF CUPERTINO FEE ESTIMATOR — BUILDING DIVISION ADDRESS: 10095 bret ave DATE: 02/131 15 REVIEWED BY: Mendez ill APN: BP#: *VALUATION: $700,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: New Construction PRIMARY SFD or Duplex 2nd Unit? Yes No PENTAMATION 1 R3SFDW USE: PERMIT TYPE: WORK construct 2 story sfdwl living area 3184s ft), attached garage 473 sq ft balcony and.patio 498 SCOPE sqft) * detached granny unit to remain* OCCUPANCY TYPE: R-3 (Custom) TYPE OF CONSTR. FLR AREA s.f. II-B,111-B,IV,V-B 4,155 TOTALS: 1 4,155 Mech. Plan ("heck 11Irutrb. Plan (31 PC FEES I PC FEE ID i BP FEES I BP FEE ID $3,288.461 IR3PLNCK 1 $3,610.861 IR3INSP $3,288.46 $3,610.86 I Elec. Plan Check ;1.leclr. l'ePrrrit Fee: I I Plumb. Permit Fee: I I 1>lec'. Permzir Fey:: �r Othcr AIerh. I I Other Plumb Insp. LJ Othet' Elec. Imp. LJ ii4ech. Insp. Lc'e. Phtnrb. hzsp. Fee: L leC. Insp. Fee: Public Works, Fire, Sanitary Sewer District, School NOTE: This estimate does not include fees due to other Departments (La Planning, information available and are only an estimate- Contact the Dept for addn'l info. District, etc.). These fees are based on the preliminary MISC ITEMS 71 FEE ITEMS Lee Resolution 11-053 Eff. 7.%1/13) FEE QTY/FEE Plan Check Fee: $3,288.46 Select a Misc Bldg/Structure or Element of a Building Suppl. PC Fee: Q Reg. Q OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $3,610.86 Suppl. Insp. Fee -(D Reg. Q OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Tax: I BCONSTAXR 1 # new units $670.76 0 _ dininish-ative Fee: G Work Without Permit? 0 Yes (j) No $0.00 Advanced Plannina Fee: IPLLONGR $581.70 Select a Non -Residential Building or Structure 0 � Travel Doc,uinenlad(.-m Fees: Strong Motion Fee: IBSEISMICR $91.00 Select an Administrative Item Bldg Stds Commission Fee 1BCBSC $28.00 :_ $8,270.78 $0.00,TOTAL $8,270.78 SUBTOTALS• :: ' Revised: 01/06/2015 CL CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10095 BRET AVE CONTRACTOR: HORIZON PERMIT NO: 15020088 CONSTRUCTION OWNER'S NAME: HSIAO SUTSEN D AND TSERNG HUAH YEU 35506 ORLEANS DR DATE ISSUED: 06/25/2015 OWNER'S PHONE: 4089730438 NEWARK, CA 94560 PHONE NO: (510) 673-4769 VW LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL License Class Lic. # -+' �' � i CONSTRUCT 2 STORY SFDWL , LIVING AREA (3184SQ FT), ATTACHED GARAGE (473 SQ FT), BALCONY AND PATIO Contractor `roAlU L Date 25 J (498 SQFT) * DETACHED GRANNY UNIT TO REMAIN* 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 Sq. Ft Floor Area: Valuation: $70000 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. APN Number: 37511023.00 Occupancy Type: APPLICANT CERTIFICATION I certify that I have read this application and state•that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED 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 WITHIN 180 DAYS OF PERMIT ISSUANCE OR upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, 180 D S FROM LAST CALLED INSP CTI N. ° costs, and expenses which may accrue against said City in consequence of the 11AU V.� Issued granting of this permit. Additionally, the applicant understands and will comply by: Date: with all non -point sou egulations per the Cupertino Municipal Code, Section 9 18. Signa Date b RE -ROOFS: _ All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. ❑ OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date: the following two reasons: 1, as owner of the property, or my employees with wages as their sole compensation, ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER 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 HAZARDOUS MATERIALS DISCLOSURE construct the project (Sec.7044, Business & Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the I hereby affirm under penalty of perjury one of the following three California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the declarations: I have and will maintain a Certificate of Consent to self -insure for Worker's Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous Compensation, as provided for by Section 3700 of the Labor Code, for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Sections 2 25533, and 25534. Section 3700 of the Labor Code, for the performance of the work for which this Owner —" —Date• 1i permit is issued. or authorized age 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 CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code, I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Address 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, ARCHITECT'S DECLARATION costs, and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section Licensed Professional 9.18. Signature Date CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 B. (408) 777-3228 - FAX (408) 777-3333 - building \� CU ATINO a-cupertino.oLcl NEW CONSTRUCTION D ADDITION El ALTERATION / TI 0 REVISION / DEFERRED ORIGINAL PERMIT # PROJED q6n�f N,, PHOftFY3 ZX09, -//- E-MAIL STREET ADD WS CLr STATE ZIPFAX C ONTACT NAME —LA E-MAIL, Lct)n -4, L RA STREPADDS CITY, STATEZ P El bWNER El mkrNER_BuiLDER ❑ OIAINERAGENT 11 CONTRACTOR El CONTRACTOR AGENT ❑ ARCHITECT —eEIGINEER 11 DEVELOPER E] TENANT F_ CONTRACTOR NAME EN SE NUMBER LICENSE LICENSE TYPE BUS. LIC 4 COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONTE ARCHITE LICENSE NUMBER pp BUS. LIC co E-MAIL ;a FAX i STREET ADDRESS CITY, STATE, ZIP DESCRIPTIO WOR ,,k e_d a U '1r'Q1-7A1 EXISTING USE PROPOSED US TU CONSTR. TYPE 9 STORIES A,,�J i�c. I _1�1 USE TYPE OCC.FT. VALUATION (S) EXISTGNEW AREA FLOOR AREA 7 DEMO AREA /., 1 _!�C) I TOTAL " i t NET AREA (rg ) _.�v -) BATHROOMHEN REMODEL AREA 94CODEJAREA OTHER REN40DEL AREA PORCH AREA DECK AREA TOTAL DECKIPORCI-I AREA GARAGE AREA: ❑AD, /��-v I jTI`ACH 2l A TACH 113. DWELLING UNITS: IS A SECOND UNIT 0 YES SECOND STORY E]YES -BEING ADDED? ONO ADDITION? ❑NO d I.Tw - PRE-APPLICATIONiTS IF YES, PR COPY OF PLANNINGA OVAL LETTER PPNo IS THE BLDG AN E] YES EICHLER HOME ? NO Rm';A yi Fagg; .4,n TOTAL VALUATION: a By my signature below, I certify to each of the following: I am the property owner or authorized afint to act on the prope owner's behalf. I have read this --f—, e. I agree to comply with all applicable local an application and the information I have provided is correct. I have read the Description of Work d verify i is ac m2 ordinances and state laws relating to bui dine construction. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes. /Ir pr ­> / 7,11, ) Signature of Applicant/Agent: - _,< 1-// -5 Date: 0 f 4'a� SUPPLEMEI\TTi"TFORMAOGN�PF-QUIRED New SFD or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building �kp for new building. 1N.'aV RW� a'Q'0,%_ _ OEM pennit _w.. , % R Commercial Bldas:. Provide a completed Hazardous Materials Disclosure PI�M=Tv% V 1 form if any Hazardous Materials are being used as part of this project. M a, -2- M — , .1 Copy of Planning Approval Letter or Meeting with Planning prior to 0— submittal ofBuilding Permit application. 1MIE,- _1_0 B1d,oApp_.:2011.doc revised 06121111 CCTV OF CUPERTINO FEE ESTIMATOR — BUILDING DIVISION ADDRESS: 10095 bret ave DATE: 02/131 15 REVIEWED BY: Mendez ill APN: BP#: *VALUATION: $700,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: New Construction PRIMARY SFD or Duplex 2nd Unit? Yes No PENTAMATION 1 R3SFDW USE: PERMIT TYPE: WORK construct 2 story sfdwl living area 3184s ft), attached garage 473 sq ft balcony and.patio 498 SCOPE sqft) * detached granny unit to remain* OCCUPANCY TYPE: R-3 (Custom) TYPE OF CONSTR. FLR AREA s.f. II-B,111-B,IV,V-B 4,155 TOTALS: 1 4,155 Mech. Plan ("heck 11Irutrb. Plan (31 PC FEES I PC FEE ID i BP FEES I BP FEE ID $3,288.461 IR3PLNCK 1 $3,610.861 IR3INSP $3,288.46 $3,610.86 I Elec. Plan Check ;1.leclr. l'ePrrrit Fee: I I Plumb. Permit Fee: I I 1>lec'. Permzir Fey:: �r Othcr AIerh. I I Other Plumb Insp. LJ Othet' Elec. Imp. LJ ii4ech. Insp. Lc'e. Phtnrb. hzsp. Fee: L leC. Insp. Fee: Public Works, Fire, Sanitary Sewer District, School NOTE: This estimate does not include fees due to other Departments (La Planning, information available and are only an estimate- Contact the Dept for addn'l info. District, etc.). These fees are based on the preliminary MISC ITEMS 71 FEE ITEMS Lee Resolution 11-053 Eff. 7.%1/13) FEE QTY/FEE Plan Check Fee: $3,288.46 Select a Misc Bldg/Structure or Element of a Building Suppl. PC Fee: Q Reg. Q OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $3,610.86 Suppl. Insp. Fee -(D Reg. Q OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Tax: I BCONSTAXR 1 # new units $670.76 0 _ dininish-ative Fee: G Work Without Permit? 0 Yes (j) No $0.00 Advanced Plannina Fee: IPLLONGR $581.70 Select a Non -Residential Building or Structure 0 � Travel Doc,uinenlad(.-m Fees: Strong Motion Fee: IBSEISMICR $91.00 Select an Administrative Item Bldg Stds Commission Fee 1BCBSC $28.00 :_ $8,270.78 $0.00,TOTAL $8,270.78 SUBTOTALS• :: ' Revised: 01/06/2015 CUPERTINO Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 Fax: 408-777-3333 CONTRACTOR / SUBCONTRACTOR LIST JOB ADDRESS: I O j.- F- . PERMIT # 90 S i � 'Y 5 Da OWNER'S NAME: 14 Wkk k PHONE # '5-1 0- G'� `'� - a' GENERAL CONTRACTOR: ilari (ANSCAWC-40V BUSINESS LICENSE # 3 ADDRESS: 00-4-010 CITY/ZIPCODE: N *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTIONS) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: V SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing S Cb N Sia--� L� p,J v -3 Electrical Excavation C8N S-rg LI.cTri pI\j 31 q3 I Fencing Flooring / Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting / Wallpaper Paving S UN 5'fi2u. � 6 A 31 a3 1 Plastering S 2 D&Y 1n fd L 30001 Plumbing Roofing Septic Tank Sheet Metal '54Q OR Y�,, L '3 6"b -0 Sheet Rock Tile - Date ?s CUPERTINO PURPOSE UTILITY RELEASE REQUEST FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL 10300 TORRE AVENUE a CUPERTINO, CA 95014-3255 (408) 777-3228 - FAX (408) 777-3333- building(ai�cugertino.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.ory/index.aspx?page=297. 2. Complete the form and obtain signatures from both the owner of the properly 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 cr,eupertino.org 4. 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): APN BLDG PERMIT #: DATE: d C SITE ADDRESS: b ve • IZT I N OWNER'S NAME: T SA SeL.A16r (Umyt YeAV) PHONE #: FAX #: MAILING ADDRESS (if different from site address). CONTRACTOR: H Dili oni ung s-raw-lr-t o•k/ PHONE #: FAX #: a b _ a- 3q1 4 CONTACT: L A N L PHONE #: FAX #: s(n _� �3 — Lt I 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 the receive all of the required final sign -offs and the City has issued a certificate of occuoancv for the building. Owner: ..............,........................................................ Print:.... ...�:.Ql...... I . ................ Contractor:.... /... ? .........................Print:......... ........ ).y ........... ................... Date: .... }1.2 .1.14... UtilityReleaseF,orm 2011.doe revised 08/09/11 CERTIFICATE OF VERIFICATION CF3 -MCH-20-H Duct Leakage Diagnostic Test (a of Project Name: 10095 Bret ve Enforcement Agency. City of Cupertino Permit Number: 15020088 Dwelling Address: 10 -045 -9 -ret Ave City.- Cupertino Zip Code: 95014 A. System information 01 Space Conditioning System Identification or Name System 1 02 Space Conditioning System Location or Area Served Downstairs 03 Building Type from CF -111 Singlefamily 04 Verified Low Leakage Ducts in Conditioned Space (VLLDCS) Credit from CF1R? No, credit is not taken 05 Verified Low Leakage Air Handling Unit (VLLAHU) Credit from CF1R? No, credit is not taken 06 Duct System Compliance Category New MCH -20a - Completely New Duct System I I 13.1 Duct leakage Diagnostic Test 01 Condenser Nominal Cooling Capacity (ton) 4 02 i Heating Capacity (kBtu/h) 78 03 Conditioned Floor Area served by this HVAC system (ft2) 1500 04 Duct Leakage Test Condition Testfinai 05 Duct Leakage Test Method Total leakage 06 Leakage Factor 0.06 07 Air Handling Unit Airflow (AHUAirflow) Determination Method Heating system method 08 I Measured AHUAirflow This field or section is not applicable 09 Calculated Target Allowable Duct Leakage (dm) 102 10 Actual duct leakage rate from leakage test measurement (cfm) 52 �llCompliance Statement System passes leakage test Registration Number: 216-A0168021A-M2000002A-M20A CA Building Energy Efficiency Standards 2013 Residential Compliance Registration Date/Time: 2016-06-1819;28:33 HERS Pro ides: CalCERTS Report Version: 2013 Rev 1.007 Schema Version: 2013.1.007 Report Generated: 2016-0 -18 19:25:12 CERTIFICATE OF VERIFICATION CF3 MCH -20-H Duct Leakage Diagnostic Test ( age 2 of 3 ) B. Duct Leakage Diagnostic Test 12 Notes C. Additional Requirements for Compliance 01 System was tested in its normal operation condition. No temporary taping allowed. for this Certificate of Verification as a whole to be determined to be in compliance. Outside air (OA) duct connections to the central forced air duct system shall not be sealed/taped off during duct leakage 02 testing. OA ducts used for Central Fan integrated (CFI) IndoorAir Quality ventilation systems, or Central Fan Ventilation Cooling Systems, that utilize dampers that open only when OA is required and automatically close when OA is not required, may configure the OA damperto the closed position during duct leakage testing. 03 All supply and return register boots were sealed to the drywall. 04 Building cavities were not used as plenums or platform returns in lieu of ducts_ 05 If cloth backed tape was used it was covered with Mastic and draw bands. 06 All connection points between the air handler and the supply and return plenums are completely sealed'.. Visual Inspection at Final Construction Stage (applicable if system was tested at rough -in) After installing the interior finishing wall and verifyingthat the above rough -in tests was completed, the following procedure must be performed 07 For all supply and return registers, verify that the spaces between the register boot and the interior finishing wall are properly sealed. 08 if the house rough -in duct leakage test was conducted without an air handier installed, inspect the connection points between the air handler and the supply and return plenums to verify that the connection points are properly sealed. 09 Inspect all joints to ensure that no cloth backed rubber adhesive duct tape is used. 10 Verification Status Pass 11 Correction Notes for this table The responsible persons signature on this compliance document affirms that all applicable requirements in this table have been met unless otherwise noted in the Verification Status and the Corrections Notes in this table. D. Determination of HERS Verification Compliance All applicable sections of this document shall indicate compliance with the specified verification protocol requirements in order for this Certificate of Verification as a whole to be determined to be in compliance. 01 Complies: All specified verification protocolrequirements on this document are met. Registration Number: 216-A0168021A-M2000002A-M20A Registration Date/Time: 2016-06-1819:28:33 HERS ProTer: CaICERTS CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.007 Report Generated: 2016-018 19:25:12 2013 Residential Compliance Schema Version: 2013.1.007 CERTIFICATE OF VERIFICATION CF3 MCH -20-H Duct leakage Diagnostic Test (F age 3 of 3 i Documentation Author s Declaration Statement .1 certify that this Certificate of Verification documentation is accurate and complete. Documentation Author Name: Kevin Harrypr1k;eI Documentation AuthorSignature:, Company: Date Signed: Allied HERS Testing 2016-06-1819:28:33 Address: CEA/ HERS Certification Identification (if applicable): 853 West LStreet City/State/Zip: Phone: Benicia CA 94510 707-373-0196 Responsible Person s Declaration statement I certify the following under penalty of perjury, under the laws of the State of California: 1. The information provided on this Certificate of Verification is true and correct. 2. 1 am the certified HERS Rater who performed the verification identified and reported on this Certificate of Verification (responsible rater . 3. The installed features, materials, components, manufactured devices, or system performance diagnostic results that require HERS verific 3tion identified on this Certificate of Verification comply with the applicable requirements in Reference Appendices RA2, RA3, and the requirei nents specified on the Certificate of Compliance for the building approved by the enforcement agency. 4. The information reportedon applicable sections ofthe Certificate(s) of installation (MR) signed and submitted by the person(s) responsible for the construction or installation conforms to the requirements specified on the Certificate(s) of Compliance (CF1R) approved by the enforcerr entagency. S. I will ensure that a registered copy of this Certificate of Verification shall be posted, or madeavailable with the building permit(s) issued or the building, and made available to the enforcement agency for all applicable inspections. 1.understandthat aregistered copy ofthisCertific teof Verification is required to be included with the documentation the builder provides to the building owner at occupancy. Builder Or Installer' Information As Shown On The Certificate Of Installation Company Name {installing Subcontractor, General Contractor, or Builder/Owner): HORIZON CONSTRUCTION Responsible Builder or Installer Name: CSLB License: Toan Ly 937861 HERS Provider Data Registry Information Sample Group Number (if applicable): Dwelling Test Status in Sample Group (if applicable) Tested HERS Rater Information HERS Rater Company Name: Allied HERS Testing Responsible Rater Name: Responsible Rater Signature: /s lCooa6v Kevin Harry Responsible Rater Certification Numberw/ this HERS Provider: Date Signed: CC2006610 2016-06-1819:28:33 Digitally signed byCa10ERTS. This digital signature is provided in orderto secure the content of this registered document, and in no responsibility for the accuracy of the information. Registration Number: 216-A0168021A-M2000002A-M20A Registration Date/Time: 2016-06-1810:28:33 CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.007 Rep 2013 Residential Compliance Schema Version: 2013.1.007 CaICERTS 19:25:12 CERTIFICATE OF VERIFICATION CF3 -MCH-23-H Space Conditioning System Airflow Rate (Page 1 of ) Project Name: 10095 Bret Ave Enforcement Agency: City of Cupertino Permit Number: 15020088 Dwelling Address: 10095 Bret Ave City: Cupertino Zip Code: 95014 A. Ducted Coating System Information (PSPP) 01 System Identification or Name System 1 02 System Location or Area Served Downstairs in 03 System Installation Type New 04 Nominal Cooling Capacity (tons) of Condenser 4 05 Condenser Speed Type Single Speed 06 Cooling System Zonal Control Type Not Zonal site at 07 Central Fan Integrated (CFl) Ventilation System Status Not a CFI system rt/ama_fas 08 . System Bypass Duct Status No Bypass Duct 09 Date of System Airflow Rate Measurement 2016-06-10 10 Airflow Rate Protocol utilized RA3.3 procedures for airflow rate measurement B. Hole for the placement of a Static Pressure Probe (HSPP), and Permanently installed' Static Pressure Probe (PSPP) in the supply plenum. is given Procedures for installing HSPP or PSPP' are specified in RA3.3.1.1. 01 Method used to demonstrate compliance with the HSPP installed and labeled consistent with FiguRA3.3-1 in 01 HSPP/PSPP requirement RA3.3.3.1A C. Airflow Rate Measurement Apparatus and Procedure Information Instrument Specifications are given in RA3-3.1.1, and system airflow rate measurement apparatus information is given in RA3.3.2. Airflow Rate Measurement Type used for this airflow rate Traditional Flow Capture Hood according to procedure in 01 verification. RA3.3.3.1A 02 Manufacturer of Airflow Measurement Apparatus Alnor 03 Model number of Airflow Measurement Apparatus EBT731 Certification Status of the Airflow Measurement Apparatus Certified by Manufacturer and listed on CEC Wet site at 04 Accuracy http://www.energy.ca.gov/titte24[equ-tpment—c rt/ama_fas Jindex.html Registration Number: 216-A0168021A-M2300002A-M23A Registration Date/Time: 2016-06-1819:28:33 HERS Provider: CaICERTS CA Building Energy Efficiency Standards 2013 Residential Compliance Report Version: 2013 Rev 1.007 Schema Version:0.555SDD Report Generated: 2016-0 -18 19:25:45 CERTIFICATE OF VERIFICATION I Space Conditioning System Airflow Rate (Fuge 2 of ) 6 MCH -23a Forced Air System Airflow Rate Measurement - Newly Installed Non -Zoned Systems or Zoned Multi -Speed Compressor D. Forced Air System Airflow Rate Measurement The procedures for System Airflow Rate Verification are specified in Reference Residential Appendix RA3.3. 01 Required Minimum System Airflow Rate (cfm/ton) 350 02 Required Minimum System Airflow Target (cfm) 1400 The airflow rate measurement, apparatus used to perform the airflow rate measurement identified on this Certificate 03 Actual System Airflow Rate Measurement (dm) 1.422 04 Compliance Statement: System airflow rate complies E. Additional Requirements 01 Air filters that meet the applicable requirements of Standards Section 150.0(m)12 or 150.0(m)13 were properly i istalled in the system during system air flow rate measurement identified on this Certificate of Verification. The airflow rate measurement, apparatus used to perform the airflow rate measurement identified on this Certificate of 02 Verification was calibrated in accordance with the apparatus manufacturer's specifications and conforms to the instrumentation specifications given in RA3.3.1. A visual inspection shall confirm that bypass ducts that deliver conditioned supply air directly to the space condi ioning 03 system return duct airflow are not used on newly constructed zonally controlled systems unless the Performanc Certificate of Compliance indicates an allowance for use of a bypass duct. When a bypass duct is accounted for on the Perk rmance Certificate of Compliance, the airflow rate shall conform to the specifications listed on the Certificate of Complia ice. 04 All registers were fully open during the diagnostic test. 05 System fan was set at maximum speed during the diagnostic test. 06 If fresh air duct is part of the HVAC system it was not closed during the diagnostic test.. 07 Airflow rate and fan watt draw shall be simultaneous measurements when used to calculate the Fan Efficacy tested value. Multi -speed compressor space cooling systems or variable speed compressor systems.shall verify air flow (cfm/t n) and fan 08 efficacy (Watt/cfm) with system operating in cooling mode at the maximum compressor speed and the maximum air handier fan speed. 09 Verification Status Pass - all applicable requirements are met 10 Correction Notes The responsible person's signature on this compliance document affirms that all applicable requirements in this tab e have been met unless otherwise noted in the Verification Status and the Corrections Notes in this table. Registration Number: 216-A0168021A-M2300002A-M23A CA Building Energy Efficiency Standards 2013 Residential Compliance Registration Date/Time: 2016-06-1819:28:33 HERS Provider: CaICERTS Report Version: 2013 Rev 1.007 Schema Version: 0.555SDD Report Generated: 2016-06-18 19:25:45 CERTIFICATE OF VERIFICATION Space Conditioning System Airflow Rate 3 of ) F. Determination of HERS Verification Compliance All applicable sections of this document shall indicate compliance with the specified verification protocol requirements in order for -this Certificate of Verification as a whale to be determined to be in compliance. 01 Complies: All specified verification protocol requirements on this document are met. Registration Number: 216-A0168021A-M2300002A-M23A Registration Date/Time: 2016-06-18 19:28:33 HERS CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.007 Report Generated: 20 2013 Residential Compliance Schema Version: 0.555SDD CaICERTS 19:25:45 CERTIFICATE OF VERIFICATION CF3 -MCH-23-H Space Conditioning System Airflow Rate (F age of Documentation Author's Declaration Statement 1.1 certify that this Certificate of Verification documentation is accurate and complete. Documentation Author Name: Kevin Harry Documentation AuthorSignature: /1 le404;L- Company: Date Signed: Allied HERS Testing 2016-06-1819:28:33 Address: CEA/HERS Certification Identification (if applicable): 853 West L Street CC2006610 City/State/Zip: Phone: Benicia CA 94510 707-373-0196 Responsible Person's Declaration statement I certify the following under penalty of perjury, under the laws of the State of California: 1. The information provided on this Certificate of Verificationistrue and correct 2. 1 am the certified HERS Rater who performed the verification identified and reported on this Certificate of Verification (responsible rater]. 3. The installed features, materials, components, manufactured devices, orsystem performance diagnostic results that require HERS verific 3tion identified on this Certificate of Verification comply with the applicable requirements in Reference Appendices RA2, RA3, and the requirei nents specified on the Certificate of Compliancefor the building approvedby the enforcement.agency.. 4. The information reported on applicable sections of the Certificate(s) of Installation (CF211) signed and submitted by the person(s) respon JbIe, for the construction or installation conforms to the requirements specified on the Certificate(s) of Compliance (CF1R) approved bythe enforcen, ent agency. S. I will ensure that a registered copy of this Certificate of Verification shall be posted, or made available with the building permit(s) issued or the building, and made available to the enforcement agency for all applicable inspeetlons.Iunderstand that aregisteredcopyofthisCertific ateof Verification is required to be included with the documentation the builder provides to the building owner at occupancy. Builder Or Installer Information As Shown On The Certificate Of Installation Company Name (Installing Subcontractor, General Contractor, or Builder/Owner): HORIZON CONSTRUCTION Responsible Builder or installer Name: CSLB License: Toan Ly 937861 HERS Provider Data Registry Information Sample Group Number (if applicable): Dwelling Test Status in Sample Group (if applicable' Tested HERS Rater Information HERS Rater Company Name: Allied HERS Testing Responsible Rater Name: Responsible Rater Signature: �> Kevin Harry Responsible Rater Certification Number w/ this HERS Provider: Date Signed: CC2006610 " 2016-06-1819:28:33 Digitally signed by Ca10ERTS. This digital signature is provided in orderto secure the content ofthis registered document, and in no wayimphes Registration responsibility for the accuracy of the information. Registration Number: 216-AO168021A-M2300002A-M23A Registration Date/Time: 2016-06-1819:28:33 HERS Pro ider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.007 Report Generated: 2016-0 -18 19:25:45 2013 Residential Compliance Schema Version: 0.555SDD CERTIFICATE OF VERIFICATION CF3 MCH -22-H Space Conditioning System Fan Efficacy (Page 1 of 3 ) Project Name: 10095 Bret Ave Enforcement Agency: City of Cupertino Permit Number: 15020088 Dwelling Address: 10095 Bret Ave City: Cupertino Zip Codes 95014 A. Ducted Cooling System Information 01 System Identification or Name System 1 02 System Location or Area Served Downstairs 03 System Installation Type New 04 Nominal Cooling Capacity (tons) of Condenser 4 05 Condenser Speed Type Single Speed 06 Cooling System Zonal Control Type Not Zonal 07 Central Fan Integrated (CFI) Ventilation System Status Not a CR system 08 System Bypass duct Status No Bypass Duct 09 Date of System Airflow Rate Measurement 2016-06-10 10 Airflow Rate Protocol utilized RA3.3 procedures for airflow rate. measurement B. Fan Watt Measurement Apparatus and Procedure Information Instrument Specifications are given in RA3.3.1, and system fan watt measurement apparatus information is I riven in RA3.3.2.2. 01 Fan Watt Verification Device Used. Portable watt meter MCH -22a Forced Air System Fan Efficacy Measurement - Newly Installed Non -Zoned Systems or Zoned Mv Iti-Speed Compressor C. Forced Air System Fan Efficacy Measurement The procedures for System Fan Watt Verification are specified in Reference Residential Appendix RA3.3. 01 Actual Tested Watts 808 02 Actual Tested Airflow -from MCH -23 (cfm) 1422 03 Required Fan Efficacy (watts/cfm) 0.58 04 Actual Fan Efficacy (watts/cfm) 0.57 05 Compliance Statement: System fan efficacy complies Registration Number: 216-A0168021A-M2200002A-M22A Registration Date/Time: 2016-06-1819:28:33 HERS Pro,, ider. CalCERTS CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.007 Report Generated: 2016-06-18 19:26:09 2013 Residential Compliance Schema Version: 0.51SDD CERTIFICATE OF VERIFICATION Space Conditioning System Fan Efficacy (I f age 2 of 3 ) I D. Additional Requirements 01 All registers were fully open during the diagnostic test. for this Certificate of Verification as a whole to be determined to be in compliance. 02 System fan was set at maximum speed during the diagnostic test. Complies: All specified verification protocol requirements on this document are met - 03 If fresh air duct is part of the HVAC system it was not closed during the diagnostictest. 04 Airflow rate and fan watt draw shall be simultaneous measurements when used to calculate the Fan Efficacy test ad value. 05 Multi -speed compressor space cooling systems or variable speed compressor systems shall verify air flow (efm/t efficacy (Watt/cfm) with system operating in cooling mode at the maximum compressor speed and the maximum handier fan speed. n) and fan air 06 Zoned cooling air distribution systems with single speed compressors shall meet both the airflow (cfm/ton) and ian (Watt/cfm) criteria in every zonal control mode. efficacy 07 Verification Status Pass - all applicable requirements are met 08 Correction Notes The responsible persons signature on this compliance document affirms that all applicable requirements in this table been met unless otherwise noted in the Verification Status and the Corrections Notes in this table. have E. Determination of HERS Verification Compliance Ali applicable sections of this document shall indicate compliance with the specified verification protocol requirements in order for this Certificate of Verification as a whole to be determined to be in compliance. 01 Complies: All specified verification protocol requirements on this document are met - Registration Number: 216-A0168021A-M2200002A-M22A Registration Date/Time: 2016-06-18 19:28:33 HERS Proider: CalCERTS CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.007 Report Generated: 2016-0 18 19:26:09 2013 Residential Compliance Schema Version: 0.51SDD CERTIFICATE OF VERIFICATION CF3 MCH -22 -It Space Conditioning System Fan Efficacy ( age 3 of 3 ) Documentation Author's Declaration Statement 1.1 certify that this Certificate of Verification documentation is accurate and complete. Documentation Author Name: Kevin Harry Documentation Author Signature: Company: Date Signed: Allied HERS Testing 2616-06-1819:28:33 Address: CEA/'HERS Certification Identification (if applicable): 853 West L Street City/State/Zip: Phone: Benicia CA 94510 707-373-0196 Responsible Person's Declaration statement I certify -the following under penalty of perjury, under the laws of the State of California: 1. The information provided on this Certificate of Verification is true and correct. 2. 1 am the certified HERS Rater who performed the verification identified and reported on this Certificate of Verification (responsible rater). 3. The installed features, materials, components, manufactured devices, or system performance diagnostic results that require HERS verification identified on this Certificate of Verification comply with the applicable requirements in Reference Appendices RA2, RA3, and the requiret nents specified on the Certificate of Compliance for the building approved by the enforcement agency. 4. The information reported on applicable sections ofthe Certificate(s) of -installation (CF2R)'. signed and submitted by the person(s) responsible for the construction or installation conforms to the requirements specified on the Certificates) of Compliance (CF1R) approved by the enforcerr entagency. 5. [will ensure that a registered copy of this Certificate of Verification shall be posted, or made available with the building permit(s) issued: or the building, and made available to the enforcement agency for all applicable inspections. Iunderstand that aregistered copy ofthisCertific iteof Verification is required to be included with the documentation the builder provides to the building owner at occupancy. Builder Or Installer Information As Shown On The Certificate Of Installation Company Name (Installing Subcontractor General Contractor, or Builder/Owner): HORIZON CONSTRUCTION Responsible Builder or Installer Name: CSLB License: Toan Ly 937861 HERS Provider Data Registry information Sample Group Number (if applicable): Dwelling Test Status in Sample Group Cif applicable) Tested HERS Rater Information HERS Rater Company Name: Allied HERS Testing Responsible Rater Name: Responsible RaterSignature: Kevin Harry Responsible Rater Certification Number w/ this HERS Provider. Date Signed: CC2006610 2016-06-18 19:28:33 Digitally signed byCaICERTS This digital signature is provided in order to secure the content ofthis registered document, and in noway implies Registration responsibility for the accuracy of the information. Registration Number: 216-A0168021A-M2200002A-M22A Registration Date/Time: 2016-0'6-1819:28:33 HERS Proider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.007 Report Generated: 2016-0 -18 19:26:09 2013 Residential Compliance Schema Version: 0.51SDD FILE,, r t eo- 1 17 CERTIFICATE OF VERIFICATION CF3 MCH -20-H Duct Leakage Diagnostic 0) Space Conditioning System Identification or Name Project Name: 10095 Bret Ave Enforcement Agency: City of Cupertino Permit Number: 15020088 Dwelling Address: 10095 ve City: Cupertino Zip Code: 14 A. System Information 01 Space Conditioning System Identification or Name System 2 02 Space Conditioning System Location or Area Served Upstairs 03 Building Type from CF -111 Single family 04 Verified Low Leakage Ducts in Conditioned Space (VLLDCS) Credit from CFiR? No, credit is not taken 05 Verified Low Leakage Air Handling Unit (VLLAHU) Credit from CF1R? No, credit is not taken 06 1 Duct System Compliance Category New MCH -20a - Completely New Duct System B. Duct Leakage Diagnostic Test 01 Condenser Nominal Cooling Capacity (ton) 3 02 Heating Capacity (kBtu/h) 58 03 Conditioned Floor Area served by this HVAC system (ft2) 1500 04 Duct Leakage Test Condition Test final 05 Duct Leakage Test Method Total leakage 06 Leakage Factor 0.06 07 Air Handling Unit Airflow (AHUAirflow) Determination Method Heating system method' 08 Measured AHUAirflow This field or section is not applicable 09 Calculated Target Allowable Duct Leakage (cfm) 76 10 Actual duct leakage rate from leakage test measurement Win) 45 11 Compliance Statement System passes leakage test Registration Number: 216-A0168021A-M2000003A-M20A Registration Date/Time: 2016-06-18 79:28:54 HERS Pro ider: Ca10ERTS CA Building Energy Efficiency Standards 2013 Residential Compliance Report Version: 2013 Rev 1.007 Schema Version: 2013.1.007 Report Generated: 2016-06-18 19:26:53 CERTIFICATE OF VERIFICATION CF3 -MGH-20-H Duct Leakage Diagnostic Test ( age 2 of 3 ) B. Duct Leakage Diagnostic Test 12 Notes C. Additional Requirements for Compliance 01 System was tested in its normal operation condition. No temporary taping allowed. for this Certificate of Verification as a whole to be determined to be in compliance. Outside air (OA) duct connections to the central forced air duct system shall not be sealed/tapedoff during duct leakage 02 testing. OA ducts used for Central Fan Integrated (CFI) Indoor Air Quality ventilation systems, or Central Fan Ventilation Cooling Systems, that utilize dampers that open only when OA is required and automatically close when OA is not required, may configure the OA damper to the closed position during duct leakage testing. 03 All supply and return register boots were sealed to the drywall. 04 Building cavities were not used as plenums or platform returns in lieu of ducts. 05 if cloth backed tape was used it was covered with Mastic and draw bands. 06 All connection points between the air handier and the supply and return plenums are completely sealed. Visual Inspection at Final Construction Stage (applicable if system was tested at rough -in) After installing the interior finishing wall and verifying that the above rough -in tests was completed, the following procedure must be performed 07 For all supply and return registers, verify that the spaces between the register boot and the interior finishing wall are properly sealed. 08 If the house rough -in duct leakage test was conducted without an air handier installed, inspect the connection p ints between the air handier and the supply and return plenums to verify that the connection points are properly sealed. 09 inspect all joints to ensure that no cloth backed rubber adhesive duct tape is used. 10 Verification Status Pass 11 Correction Notes for this table , The responsible persons signature on this compliance document affirms that all applicable requirements in this table have been met unless otherwise noted in the Verification Status and the Corrections Notes in this table. D. Determination of HERS Verification Compliance All applicable sections of this document shall indicate compliance with the specified verification protocol requirement5 in order for this Certificate of Verification as a whole to be determined to be in compliance. 01 Complies: All specified verification protocol requirements on this document are met. Registration Number: 216-A0168021A-M2000003A-M20A Registration Date/Time: 2016-06-18 19:28:54 HERS Pro ider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.007 Report Generated: 2016-0 -18 19:26:53 2013 Residential Compliance Schema Version: 2013.1.007 CERTIFICATE OF VERIFICATION CF3 MCH -20-H Duct Leakage Diagnostic Test ( age 3 of 3 ) Documentation Author s Declaration Statement . I certify that this Certificate of Verification documentation is accurate and complete. Documentation Author Name: Kevin Harry Documentation Author Signature: 1ClJGlL Company: Date Signed: Allied HERS Testing 20"16-06-1819:28:54 Address: CEA/ HERS Certification Identification (if applicable): 853 West L Street City/State/Zip: Phone: Benicia CA 94510 707-373-0196 Responsible Person s Declaration statement I certify the following under penalty of perjury, under the laws of the State of California: 1. The information provided on this Certificate of Verification is true and correct. 2. 1 am the certified HERS Raterwho performed theverification identified and reported on this Certificate of Verification (responsible rater). 3. The installed features, materials, components, manufactured devices, or system performance diagnostic results that require HERS verific ition identified on this Certificate of Verification comply with the applicable requirements in Reference Appendices RA2, RA3, and the requirements specified on the Certificate of Compliance forthe building approved bythe enforcement agency. 4. The information reported on applicable sections ofthe Certificate(s) of Installation (CF2R) signed and submitted by the person(s) responsible for the construction or installation conforms to the requirements specified on the Certificate(s) of Compliance jCF1R) approved by the enforcerr ent agency. 5. 1 will ensure that a registered copy of this Certificate of Verification shall be posted, or made available with the building permit(s) issued orthe building, and made available to the enforcement agency for all a pplicable inspections. I understand that a registered copy of this Certiffic;teof Verification is required to be included with the documentation the builder provides to the building owner at occupancy. Builder Or Installer Information As Shown On The Certificate Of Installation Company Name (Installing Subcontractor, General Contractor, or Builder/Owner): HORIZON CONSTRUCTION Responsible Builder or Installer Name: CSLB License: Toan Ly 937861 HERS Provider Data Registry information Sample Group Number (if applicable): Dwelling Test Status in Sample Group (if applicable) Tested HERS Rater Information HERS Rater Company Name: Allied HERS Testing Responsible Rater Name: Responsible Rater Signature_ �> Kevin Harry Responsible Rater Certification Number w/ this HERS Provider: Date Signed: CC2006610 2016-06-18 19:28:54 Digitally signed byCaICERTS This digital signature is provided in orderto secure the content of this registered document and in no wayimplies Registration responsibility for the accuracy of the information. Registration Number: 216-A0168021A-M2000003A-M20A Registration Date/Time: 2016-06-18 19:28:54 HERS Pro1-18 der: CaICERTS CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.007 Report Generated: 2016-0 19:26:53 2013 Residential Compliance Schema Version: 2013.1.007 CERTIFICATE OF VERIFICATION CF3 MCH -23-H Space Conditioning System. Airflow Rate (F age 1 of Project Name: 10095 Bret Ave Enforcement Agency. City of Cupertino Permit Number: 15020088 Dwelling Address: 1.0095 Bret Ave City: Cupertino Zip Code: 95014 A. Ducted Cooling System Information (PSPP) 01 System Identification or Name System 2 02 System Location or Area Served Upstairs RA3.3-1 03 System Installation Type New 04 Nominal Cooling Capacity (tons) of Condenser 3 05 Condenser Speed Type Single Speed 06 Cooling System Zonal Control Type Not Zonal at 07 Central Fan Integrated (CFI) Ventilation System Status Not a CFI system 08 System Bypass Duct Status No Bypass Duct 09 Date of System Airflow Rate Measurement 2016-06-10 10 Airflow Rate Protocol utilized RA33 procedures for airflow rate measurement B. Hole for the placement of a Static Pressure Probe (HSPP), and Permanently installedStatic Pressure Probe (PSPP) in the supply plenum. is given Procedures for installing HSPP or PSPP are specified in RA3 3.1.1. 01 Method used to demonstrate compliance with the HSPP installed and labeled consistent with Figur RA3.3-1 01 HSPP/PSPP requirement RA3.3.3.1.4 C. Airflow Rate Measurement Apparatus and Procedure Information Instrument Specifications are given in RA3.3.1.1, and system airflow rate measurement apparatus information is given in RA3.3.2. Airflow Rate Measurement Type used for this airflow rate Traditional Flow Capture Hood according to proc dare in 01 verification. RA3.3.3.1.4 02 Manufacturer of Airflow Measurement Apparatus Alnor 03 Model number of Airflow Measurement Apparatus EBT731 Certification Status of the Airflow Measurement Apparatus Certified by Manufacturer and listed on CEC Website at 04 Accuracy http://www.energy.ca.gov/title24/equipment—c(!rt/ama—fas /index.htmi Registration Number: 216-A0168021A-M2300003A-M23A Registration Date/Time: 2016-06-181928:54 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.007 2013 Residential Compliance Schema Version: 0.555SDD Report Generated: 2016-06-18 19:27:24 CERTIFICATE OF VERIFICATION Space Conditioning System Airflow Rate 2 of ) IMCH -23a Forced Air System Airflow Rate Measurement - Newly Installed Non -Zoned Systems or Zoned MIti-Speed Compressor D. Forced Air System Airflow Rate Measurement The procedures for System Airflow Rate Verification are specified in Reference Residential Appendix RA3.3. 01 Required Minimum System Airflow Rate (cfmAon) 350 02 Required Minimum System Airflow Target (cfm) 1050 The airflow rate measurement apparatus used to perform the airflow rate measurement identified on this Certificate 03 Actual System Airflow Rate Measurement (cfm) 1073 04 Compliance Statement: System airflow rate complies E. Additional Requirements 01 Air filters that meet the applicable requirements of Standards Section 150.0(m)12 or 150.0(m)13 were properly installed in the system during system airflow rate measurement identified on this Certificate of Verification. The airflow rate measurement apparatus used to perform the airflow rate measurement identified on this Certificate of 02 Verification was calibrated in accordance with the apparatus manufacturer's specifications and conforms to the instrumentation specifications given in RA3.3.1. A visual inspection shall confirm that bypass ducts that deliver conditioned supply air directly to the space concill ioning 03 system return duct airflow are not used on newly constructed zonally controlled systems unless the Performance Certificate of Compliance indicates an allowance for use of a bypass duct. When a bypass duct is accounted for on the Performance Certificate of Compliance, the airflow rate shall conform to the specifications listed on the Certificate of Compliance. 04 All registers were fully open during the diagnostic test. 05 System fan was set at maximum speed during the diagnostic test. 06 if fresh air duct is part of the HVAC system it was not closed during the diagnostic test. 07 Airflow rate and fan watt draw shall be simultaneous measurements when used to calculate the fan Efficacy test ad value. Multi -speed compressor space cooling systems or variable speed compressor systems shall verify air flow (cfm/t n) and fan 08 efficacy (Watt/cfm) with system operating in cooling mode at the maximum compressor speed and the maximur 1 air handler fan speed. 09 Verification Status' Pass - all applicable requirements are met 10 Correction Notes The responsible person's signature on this compliance document affirms that all applicable requirements in this tab a have been met unless otherwise noted in the Verification Status and the Corrections Notes in this table. Registration Number: 216-A0168021A-M2300003A M23A CA Building Energy Efficiency Standards 2013 Residential Compliance Registration Date/Time: 2016-06-1819:28:54 Report Version: 2013 Rev 1.007 Schema Version: 0.555SDD HERS Pro ider: CaICERTS Report Generated: 2016-06-18 1927:24 CERTIFICATE OF VERIFICATION CF3 MCH -23-H Space Conditioning System Airflow Bate age 3 of j F. Determination of HERS Verification Compliance All applicable sections of this document shall indicate compliance with the specified verification protocol requirements in order for this Certificate of Verification as a whole to be determined to be in compliance. 01 Complies: All specified verification protocol requirements on this document are met. Registration Number: 216-A0168021A-M2300003A-M23A Registration Date/Time: 2016-06-1819:28:54 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report version: 2013 Rev 1.007 Report Generated: 2016-06-18 19:27:24 2013 Residential Compliance Schema Version: 0.555SDD CERTIFICATE OF VERIFICATION CF3R MCH -23-H Space Conditioning System Airflow Rate (Page of j Documentation Author's Declaration Statement 1.1 certify that this Certificate of Verification documentation is accurate and complete. Documentation Author Name: Kevin Harry Documentation AuthorSignature: 1eAo1Z;1i Company: Date Signed: Allied HERS Testing 2016-06-1819:28:54 Address: CEA% HERS Certification Identification (if applicable): 853 West L Street CC2006610 City/State/Zip: Phone: Benicia CA 94510 707-373-0196 Responsible Person's Declaration statement I certify the following under penalty of perjury under the laws of the State of California: 1. The information provided on this Certificate ofVerification is true and correct. 2. 1 am the certified HERS Raterwho performed the verification identified' and reported on this Certificate of Verification (responsible rater). 3. The installed features, materials, components, manufactured devices, or system performance diagnostic results that require HERS verific ition identified on this Certificate of Verification comply with the applicable requirements in Reference Appendices RA2, RA3, and the requirements specified on the Certificate ofCompliance for the building approved bythe enforcement agency. 4. The information reported on applicable sections of the Certificate(s) of Installation (CF2R) signed and submitted by the person(s) responsible for the construction or installation conforms to the requirements specified on the Certificate(s) of Compliance (CFiR) approved bythe enforcerr ent agency. 5. ]will ensure that a registered copy of this Certificate of Verification shall be posted, or made available with the building permit(s) issued nr the building, and made available to the enforcement agency for all applicable inspections. I understand that a registered copy of this Certific to of Verification is required to be included with the documentation the builder provides to the building owner at occupancy. Builder Or Installer; Information As Shown On The Certificate Of installation Company Name (installing Subcontractor, General Contractor, or Builder/Owner): HORIZON CONSTRUCTION Responsible Builder or Installer Name: CSLB License: Toan Ly 937861 HERS Provider Data Registry information Sample Group Number (if applicable): Dwelling Test Status in Sample Group (if applicable) Tested HERS Rater information HERS Rater Company Name: Allied HERS Testing Responsible Rater Name: Responsible RaterSignature: Kevin Harry Responsible Rater Certification Number w/ this HERS Provider: Date Signed: CC2006610 2016-06-1819:28:54 Digitally signed byCaICERTS. This digital signature is provided in order to secure the content ofthis registered document, and in no wayimpftes Registration responsibility for the accuracy of the information. Registration Number: 216-A0168021A-M2300003A-M23A Registration Date/Time: 2016.06-1819:28:54 HERS Pi CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.007 Report Generated: 2016 2013 Residential Compliance Schema Version: 0.555SDD CaIGERTS 19:27:24 CERTIFICATE OF VERIFICATION CF3 -MCH-22-H Space Conditioning System Fan Efficacy ( age 1 of 3 ) Project Name: 1.0095 Bret Ave Enforcement Agency: City of Cupertino Permit Number: 15020088 Dwelling Address: 10095 Bret Ave City: Cupertino Zip Code: 95014 A. Ducted Cooling System Information 01 System Identification or Name System 2 02 System Location or Area Served Upstairs 03 System Installation. Type New 04 Nominal Cooling Capacity (tons) of Condenser 3 05 Condenser SpeedType Single Speed 06 Cooling System Zonal Control Type Not Zonal 07 Central Fan Integrated (CFI) Ventilation System Status Not a CFI system 08 System Bypass Duct Status No Bypass Duct 09 Date of System Airflow Rate Measurement 2016-06-10 10 Airflow Rate Protocol utilized RA3.3 procedures for airflow rate measurement B. Fan Watt Measurement Apparatus and Procedure Information Instrument Specifications are given in RA3.3.1, and system fan watt measurement apparatus information is given in RA3.3.2.2. 01 Fan Watt Verification Device used. Portable watt meter MCH -22a Forced Air System Fan Efficacy Measurement - Newly installed Non -Zoned Systems or Zoned M Iti-Speed Compressor C. Forced Air System Fan Efficacy Measurement The procedures for System Fan Watt Verification are specified in Reference Residential Appendix RA3.3. 01 Actual Tested Watts 597 02 Actual Tested Airflow from MCH -23 (cfm) 1073 03 Required Fan Efficacy(watts/cfm) 0.58 04 Actual Fan Efficacy (watts/cfm) 0.56 05 Compliance Statement: System fan efficacy complies Registration Number: 216-A0168021A-M2200003A-M22A CA Building Energy Efficiency Standards 2013 Residential Compliance Registration Date/Time: 2016-06-18 19:28:54 HERS Provider: CaICERTS Report Generated: 2016-05-18 19:27:46 Report Version: 2013 Rev 1.007 Schema Version: 0.51SDD CERTIFICATE OF VERIFICATION I Space Conditioning System Fan Efficacy (0age 2 of 3 ) D. Additional Requirements 01 All registers were fully open during the diagnostic test. for this Certificate of Verification as a whole to be determined to be in compliance. 02 System fan was set at maximum speed during the diagnostic test - Complies: All specifiedverification protocol requirements on this document are met. 03 If fresh air duct is part of the HVAC system it was not closed during the diagnostic test_ 04 Airflow rate and fan watt draw shall be simultaneous measurements when used to calculate the Fan Efficacy test ed value. 05 Multi -speed compressor space cooling systems or variable speed compressor systems shall verify air flow (cfm/t efficacy (Watt/cfm) with system operating in cooling mode at the maximum compressor speed and the maximum handlerfan speed. n) and fan air 06 Zoned cooling air distribution systems with single speed compressors shall meet both the airflow (cfm/ton) and ian (watt/cfm) criteria in every zonal control mode. efficacy 07 Verification Status Pass - all applicable requirements are met 08 Correction Notes The responsible persons signature on this compliance document affirms that all applicable requirements inthis table been met unless otherwise noted in the Verification Status and the Corrections Notes in this table. have E. Determination of HERS Verification Compliance All applicable sections of this document shall indicate compliance with the specified verification protocol requirements in order for this Certificate of Verification as a whole to be determined to be in compliance. 01 Complies: All specifiedverification protocol requirements on this document are met. Registration Number: 216-A0168021A-M2200003A-M22A Registration Date/Time: 2016-06-18 19:28:54 HERS Pro ider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.007 Report Generated: 2016-06-18 19:27:46 2013 Residential Compliance Schema Version: 0.51SDD CERTIFICATE OF VERIFICATION I Space Conditioning System fan Efficacy (0age 3 of 3 ) 0 Documentation Author's Declaration Statement 1.1 certify that this Certificate of Verification documentation is accurate and complete. Documentation Author Name: Kevin Harry Documentation Author Signature: Jp,(/G1lj Company: Date Signed: Allied HERS Testing 2016-06-1819:28:54 Address: CEA/ HERS Certification Identification (if applicable): 853 West L Street City/State/Zip: Phone: Benicia CA 94510 707-373-0196 Responsible Person's Declaration statement I certify the following under penalty of perjury, under the laws of the State of California: 1. The information provided on this Certificate of Verification is true and correct. 2. 1 am the certified HERS Rater who performed the verification identified and reported on this Certificate of Verification (responsible rater'. 3. The installed features, materials, components, manufactured devices, or system performance diagnostic results that require HERS verification identified on this Certificate of Verification comply with the applicable requirements in Reference Appendices'RA2, RA3, and the requirements specified on the Certificate of Compliance for the building approved by the enforcement agency. 4. The information reported on applicable sections of the Certificate(s) of Installation (CF211) signed and submitted by the person(s) respon ible for the construction or installation conforms to the requirements specified on the Certificates) ofCompiiance (CFiR) approved bythe enforcery ient agency. S. 1 will ensure that a registered copy of this Certificate of Verification shall be posted, or made available with the building permit(s) issued; or the building, and made available to the enforcement agency for all applicable inspections. F understand that a registered copy of this Certific 3te of Verification is required to be included with the documentation the builder provides to the building owner at occupancy. Builder Or installer Information As Shown On The Certificate Of Installation Company Name (Installing Subcontractor, General Contractor, or Builder/Owner). HORIZON CONSTRUCTION Responsible Builder or Installer Name: CSLB license:. Toan Ly 937861 HERS Provider Data Registry information Sample Group Number (if applicable): Dwelling Test Status in Sample Group (if applicable) Tested HERS Rater Information HERS Rater Company Name: Allied HERS Testing Responsible Rater Name: Responsible Rater Signature; Kevin Harry Responsible Rater Certification Numberw/this HERS Provider; Date Signed: CC2006610 2016-06-18 19:28:54 Digitallysigned by CaICERTS. This digital signature is provided in order to secure the content of this registered document and in no wayimphes Registration responsibility for the accuracy of the information. Registration Number: 216-AO168021A-M2200003A-M22A Registration Date/Time: 2016-06-1819:28:54 HERS Pro ider: CaiCERTS CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.007 Report Generated: 2016-0-18 19:27:46 2013 Residential Compliance Schema Version: 0.51SDD