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15030098CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 1106 DERBYSHIRE DR CONTRACTOR: SUN MATTHEW M AND PERMIT NO: 15030098 WANG CHRISTINA OWNER'S NAME: SUN MATTHEW M AND WANG CHRISTINA 1106 DERBYSHIRE DR DATE ISSUED: 09/08/2015 OWNER'S PHONE: 4083138445 CUPERTINO, CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑ CONSTRUCT ONE STORY ADDITION (724 SQ FT); INTERIOR License Class Lie. # REMODEL (1200 SQ FT); ELEC PANEL UPGRADE (200 AMP); REMOVE AND RELOCATE FURNACE AND WATER 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: Sq. Ft Floor Area: Valuation: $200000 t. 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. APN Number: 36221038.00 Occupancy Type: 2. 1 have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. PERMIT EXPIRES IF WORK IS NOT STARTED APPLICANT CERTIFICATION WITIIIN 180 DAYS OF PERMIT ISSUANCE OR I certify that I have read this application and state that the above information is ALLED INSPECTION. 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, Issued by: Date: 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. RE -ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is Signature Date installed without first obtaining an inspection, I agree to remove all new materials for inspection. OWNER -BUILDER DECLARATION Signature of Applicant: Date: I hereby affirm that I am exempt from the Contractor's License Law for one of ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER the following two reasons: t. 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 HAZARDOUS MATERIALS DISCLOSURE sale (Sec.7044, Business & Professions Code) I have read the hazardous materials requirements under Chapter 6.95 of the 2. I, as owner of the property, am exclusively contracting with licensed contractors to California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain construct the project (Sec.7044, Business & Professions Code). compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. I hereby affirm under penalty of perjury one of the following three declarations: Additionally, should I use equipment or devices which emit hazardous air 1. I have and will maintain a Certificate of Consent to self -insure for Worker's contaminants as defined by the Bay Area Air Quality Management District I will Compensation, as provided for by Section 3700 of the Labor Code, for the maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the performance of the work for which this permit is issued. Health & Safety Code, Sections 25505, 25533, and 25534. 2: 1 have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized agent: Date: .4 permit is issued. a. 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 CONSTRUCTION LENDING AGENCY Compensation laws of California. If, after making this certificate of exemption, I I hereby affirm that there is a construction lending agency for the performance of work's become subject to the Worker's Compensation provisions of the Labor Code, I for which this permit is issued (Sec. 3097, Civ C.) must forthwith comply with such provisions or this permit shall be deemed Lender's Name revoked. Lender's Address APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is ARCHITECT'S DECLARATION correct. I agree to comply with all city and county ordinances and state laws relating I understand my plans shall be used as public records. to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save Licensed Professional 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 Date 14 6 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: 15030098 1106 DERBYSHIRE DR CUPERTINO CA 95014 (362 21 038) K C WU CONSTRUCTION FREMONT, CA 94539 OWNER'S NAME: SUN MATTHEW M AND WANG CHRISTINA DATE ISSUED: 09/08/2015 OWNER'S PHONE: (510) 206-1602 PHONE NO: (510) 364-8964 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class PLUMBING Lic. #810425 0O Contractor K C WU CONSTRUCTION Date 07/31/2018 —BLDG— ELECT — I MECH RESIDENTIAL COMMERCIAL 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. JOB DESCRIPTION: CONSTRUCT ONE STORY ADDITION (724 SQ FT); INTERIOR I hereby affirm under penalty of perjury one of the following two declarations: REMODEL (1200 SQ FT); ELEC PANEL UPGRADE (200 1. I have and will maintain a certificate of consent to self -insure for Worker's AMP); REMOVE AND RELOCATE FURNACE AND WATER HEATER. Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. REVISION #1: REMOVE (3) WINDOWS FROM RIGHT SIDE OF I have and will maintain Worker's Compensation Insurance, as provided for by RESIDENCE - SEE REVISED STRUCTURAL PLAN SHEETS. ISSUED K<:2. Section 3700 of the Labor Code, for the performance of the work for which this 10.14.16. permit is issued. APPLICANT CERTIFICATION Sq. Ft Floor Area: Valuation: $200000.00 I certify that I have read this application and state that the above APN Number: Occupancy Type: information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize 362 21 038 R3 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 PERMIT EXPIRES IF WORK IS NOT STARTED may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point WITHIN 180 DAYS OF PERMIT ISSUANCE OR source regulations er the Cupertino Municipal Code, Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. Signature � 1 Date 10,1416 Issued by: SEAN HATCH OWNER-BUILDVR DECLARATION Date: 09/08/2015 I hereby affirm that I am exempt from the Contractor's License Law for one of the RF_ROOFS: following two reasons: All roofs shall be inspected prior to any roofing material being installed. If a roof is r. I, as owner of the property, or my employees with wages as their sole installed without fust obtaining an inspection, I agree to remove all new materials for compensation, will do the work, and the structure is not intended or offered for inspection. sale (Sec.7044, Business & Professions Code) z. I, as owner of the property, am exclusively contracting with licensed Signature of Applicant: contractors to construct the project (Sec.7044, Business & Professions Code). Date: 10, 14.16 1 hereby affirm under penalty of perjury one of the following three declarations: 1. I have and will maintain a Certificate of Consent to self -insure for Worker's ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE z. I have and will maintain Worker's Compensation Insurance, as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the Section 3700 of the Labor Code, for the performance of the work for which this California Health & Safety Code, Sections 25505, 25533, and 25534. I will permit is issued. maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the 3. I certify that in the performance of the work for which this permit is issued, I Health & Safety Code, Section 25532(a) should I store or handle hazardous shall not employ any person in any manner so as to become subject to the material. Additionally, should I use equipment or devices which emit hazardous Worker's Compensation laws of California. If, after making this certificate of air contaminants as defined by the Bay Area Air Quality Management District I exemption, I become subject to the Worker's Compensation provisions of the will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sec ons 25505, 25533, and 25 34. Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. Owner or authorized agent: APPLICANT CERTIFICATION Date: 10,14.16 1 certify that I have read this application and state that the above information is CONSTRUCTION LENDING AGENCY correct. I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending agency for the performance relating to building construction, and hereby authorize representatives of this city of work's for which this permit is issued (Sec. 3097, Civ C.) to enter upon the above mentioned property for inspection purposes. (We) agree Lender's Name to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in Lender's Address consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION Code, Section 9.18. 1 understand my plans shall be used as public records. Signature Date 10.14.16 Licensed Professional - U -A CUPERT1W F� NEW coNSTRuc CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT o BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 �� B. (408) 77..773228 e FAX (408) 777-3333 ^ building-)-cupertino.org PION. .. V Ar)T-)TTTONT I I AT -,Pp A-nn-T/TT I RFVTCTr)v/T)Pm:T?RFTI OT?7r:TTTAT DT_ NITT1! PROJECT AD SS jj APN °� �I � ?O 0'"74ER NAME 4 lel: , i6 ->r CX. Gi 6'L PHONE S� ® cif% `-� 6 U Z E-MAIL I i 1� `- '� L W �� I ZCo" Y11Gtii I •, G�T11��. ST REE CITY, STATE, ZIP. FAX -11S- SD GSL c OTTACT N,,A,,�ffE G1,Lt � liliLi n LA Gam... PH N MAIL / t L � 1 ��7 I � GtL1Cf2 i2i �GG�I Ciu7�— STREET ADD SS.- ��{�p��CITY, STA E, ZIP ` FAX .'L/./.f.��C_ bill'4 ' ❑' o A,DmR `• '❑ OWNER -BUILDER:-* ` ❑ OWNER AGENT ❑ CONTRACTOR r • ❑ CONTRACTOR AGEIrr ARCHITECT ❑ ENGINEER. -,❑ DEVELOPER- ❑, TiNANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS. LIC n COMPANY NAME I E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE CHITECTiE%GINEER NAME LICENSE NUMBER BUS, LIC R C -28 4 COMPANYNAME J Lkc i11 -MAIL/ I �✓d2_.. FAX C Gi.0 CGZ L> STREET ADDRESS CT} Y, STATE ZIP / q HO1�E DEsCRIPTt N. F WORK _ hey 4-,eA Ae `t�u 1 'r' Iso c C( )yN Ire f%,.� • 4 v,t i-Dr2 w/ A urc� lOCAI t' (m to e t J1 d /- ker"ka-, e- i/i kj AddCL i r Iv -nnuYYL- Sr ay yvrrwk '-e t J blelct lr -O 2 A--r-eA lit O rc. �Q . 2 { �C- I i L'c Ah -e l ..-t-c .1„e�... .. ..... . EXISTLNG USE PROPOSED USE CONSTR TYPE R STORIE SSI v / USE TYPE OCC. SQ.FT. VALUATION (S) EXISTG/�7 AREA 1 `�'7� NeW FLOOR AREA 2 DEMO AREA TOTAL NET AREA 2 BATHROOM KITCHEN REMODEL AREA `� REMODEL AREA OTHER REMODEL AREA /./'�Is• J PORCH AREA 2 DECK AREA TOTAL DECIUPORCH AREA Z GARAGE AREA: DETACH 'RATTACH I//4f✓v D%VELLrNG UNITS: ISA SECOND UNIT ❑YES SECOND STORY []YES BEINGADDED? W0 ADDITION? 'j N0 PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF PLAN TING APPL R ''I� O PLANR\W G APPROVAL LETTER IS THE BLDG AN El YES EICHLER HOME? .y��X�O SEI V.ED.$ 3 # �; _-: '" �s "n, ^�- TOTAL �A�UATION: / y� __ • . ,,,, - 06 By my signature below, I certify to each of the following; . I am the properly owner or authorized agent to act on Ie owner's behalf. I have read this application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building con ruction. I authorize representatives of Cupertino to enter the �aabove-idenjtifed property four inspection purposes. Signature of Applicant/Aeent: —C' -(��D� � Date: j (La I,-- SUPPLE -MENTAL INFORMA 0 REQUIRED r - New SFD or Multifamilydwellings: Apply for demolition permit for PP Y P] a. COURrER r rr 87�� o F existing building(s). Demolition permit is required prior to issuance of building3 for building. pyER THE N.2 Offi ��;�� s 1 DAG YL REVIE\y ��gym x permit new Ear�tr ss Y I.�,�ts�L�n,REJUM Commercial Bldgs: Provide Hazardous Materials Disclosure k � � ' j Q _ a completed srat.D�uzD�y P Iii%�titilts �' form if any Hazardous Materials are being used as part of this.project, Copy of Planning Approval Letter or Meeting «vith Planning prior to DJOR tg srrARY sExD�sTLirc� submittal of Building Permit application. - R B1dgApp_2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR BUILDING DIVISION OCCUPANCY TYPE: 1106 derbyshire dr DATE: 03/16/20015 REVIEWED BY: Mendez JimADDRESS: APN: BP#: ��(��O�.d "VALUATION: 1$200,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Addition PRIMARY USE: SFD or Duplex 2nd Unit? •' Yes No OTC? YesNo PENTAMATION PERMIT TYPE: 1 R3SFDADD WORK add 724 sq ft to front and side of sfdwl remodel throw ht out 1200 sq ftto include 200 amp panel SCOPE upgrade 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 724 $2,654.00 IR3PLNCK $1,666.00 IRMNSP Elec. Insp. Fee: Permit Fee: $1,666.00 Suppl. Insp. Fee:E) Reg. Q OT 0.0 1 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Tax:r _T rlclininistrative Fee: I 0 E) Work Without Permit? 0 Yes (j) No $0.00 Advanced Planning Fee: IPLLONGR TOTALS: 724 $2,654.00 '; $1,666.00 $26.00 MECH; I OURL YQs :' No PLUMB, HOURLY , :;Q Yes .& No: ELEC, IiOUIiLY: r Yes" :llech. Plan C:'heck Plrurb. Plan Cher/ Flee.. Plan Cheek iblech. Permit Fee: P111mJi. Permit / ee: F.lec.. Permit Fee: Other ;i9ech. Insp.E3-L- Other Plumb In.sp. Other Elcr. Insp. rllech. Insp. Fac: Plumb. Insp. F'ee: Elec. Insp. Fee: NOTE: This estimate does not include fees due to other Departments (i.a Planning, Public Works, Fire, Sanitary Sewer District, School District. etc). These fees are based on the nreliminary information available and are only an estimate. Contact the Dent for addn'1 into. FEE ITEMS (Fee Resolution 11-053 Eff 7/1/13) FEE � QTY/FEE I MISC ITEMS Plan Check Fee: $2,654.00 FT -2661 s.f. Remodel, Other $4,604.00 IREMRES2 Suppl. PC Fee: E) Reg. 0 OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $1,666.00 Suppl. Insp. Fee:E) Reg. Q OT 0.0 1 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Tax:r _T rlclininistrative Fee: 0 E) Work Without Permit? 0 Yes (j) No $0.00 Advanced Planning Fee: IPLLONGR $101.36 Select a Non -Residential G Building or Structure 0 I i Travel Docilmentation Fees: Strong Motion Fee: IBSEISAffCR $26.00 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $8.00 :. SUBTOTALS r $4,455.36 $4,604.00 - TOTALrFEE„- $9,059.36 Revised: 02/14/2015 VAN A S -tt ClIb 1-tCOV r V,c ( m Jk -� 1'5 0 --� () 0 9 F I cl- /Z,z"I1,-b ( 6, Sze+ct-ber- Z2. �, no\jj vlllx�y MCA444"t" Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 C U' P E RTI N O_ Telephone: 408-777-3228 Fax: 408-777-3333 CONTRA CTOR / SUBCONTRACTOR LINT JOB ADDRESS: Ito ,& !?K -KB ARE P PERMIT # 1 1�-3 I(® OWNER'S NAME: C, �4KtSTINA V(A-N "-` PHONE # GENERAL CONTRACTOR: Caro+- r C 8BUSINESS LICENSE #>1�7 ADDRESS: CITY/ZIPCODE: o6Z *Our municipal code req u res all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED Al CITY OF CUPERTINO BUSINESS LICENSE. j I am not using any subcontractors:_ Signature - Date _ Please check applicable subcontractors and complete the following information: o Owner / Contractor Signature SUBCONTRACTOR Cabinets & Millwork BUSINESS NAMESUSINE i SS LICENSE # Cement Finishing Electrical j{ ,' jiJ Excavation r- Fencing Flooring / Carpeting Linoleum / Wood N✓ Glass /Glazing Heating UA co s_ vItc-f 1-12 n CCC e �s ca 2 t i - X62 g Insulation Landscaping Lathing Masonry `. i/ Painting / Wallpaper�- Paving �I Plastering C W J o -10 V) �L_l J Plumbing te g Roofing Septic Tank V Sheet Metal Sheet Rock ve6l'it , i 4s 3 j j Tile o Owner / Contractor Signature \e"../ SMOKE / CARBON MONOXIDE ALARMS OWNER CERTIFICATE OF COMPLIANCE 4,.44, COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION CUPERTINO 10300 TORRE AVENUE• CUPERTINO,CA 95014-3255 (408)777-3228• FAX(408)777-3333• buildinqacupertino.orq Q p isT�r',ess /6t wg(3Li5s'-ItRE PR , .oW.l IaamssSrrioke: '7 " C rb_o0 ►°a'"'g"o•"'cie PERMIT CANNOT BE FINAL' AND COMPLETED UNTIL TRIS CERTIFICATE BEEN,SIGNED AND RETURNED TO TILE BUILDING DIVISION .... ,m,_ .,:.. -..:."-».. __..,.:, ,,;'... ,, ,..•,mss PURPOSE This affidavit is a sell-certification for the installation of all required Smoke and Carbon Monoxide Alarms for compliance with 2013 CRC Section R314,2013 CBC Sections 420.6 and 907.2.11.2 where no interior access for inspections are required. GENERAL INFORMATION Existing single-family and multi-family dwellings shall be provided with Smoke Alarms and Carbon Monoxide alarms. When the valuation of additions, alterations, or repairs to existing dwelling units exceeds $1000.00, CRC Section R314 and CBC Sections 907.2.11.5 and 420.6 require that Smoke Alarms and/or Carbon Monoxide Alarms be installed in the following locations: AREA SMOKE ALARM COALARM__ Outside of each separate sleeping area in the immediate vicinity of the X X bedroom(s) On'every level of a dwelling unit including basements X X Within each sleeping room _ X • Carbon Monoxide alarms are not required in dwellings which do not contain fuel-burning appliances and that do not have an attached garage. Carbon monoxide alarms combined with smoke alarms shall comply with CBC Section 420.6 and shall be approved by the.Office of the State Fire Marshal. Power Supply:In dwelling units with no commercial power supply, alarm(s)may be solely battery operated. In existing dwelling units, alarms are permitted to be solely battery operated where repairs or alterations do not result in the removal of wall and ceiling finishes or there is no access by means of attic,basement or crawl space.Refer to CRC Section R314 and CBC Sections 907.2.11.4 and 420.6.2. An electrical permit is required for alarms which must be connected to the building wiring. As owner of the above-referenced property,I hereby certify that the alarm(s) referenced above has/have been installed in accordance with the manufacturer's instructions and in compliance with the California Building and California Residential Codes. The alarms have been tested and are operational, as of the date signed below. I have read and a.ree to corn.l with the terms and conditions of this statement Irbwrier CM=agentts)1 el: ChriStWaJ aigmatere D;a e. "VWf!(r.. ontractor-gam e: jrl/ / �L / on1 - i°Lfcf�G 1Si nature .. ... ....t`��.Ca V1 Lic.:`3/v`� Date: Smoke and CO foim.doc revised 03/1 WATER -CONSERVING PLUMBING FIXTURES 0 i OWNER CERTIFICATE OF COMPLIANCE COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION CUPERTINO 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 Owner Name Address ('408) 777-3228 • FAX (408) 777-3333 - building(a)-cupertino.org c h lis , &_ �1q," -' Permit No. /S-0 3 ® A 1 Is your real property a registered historical site? ❑ Yes Civil Code Sections 1101 1 through 1101.8 do not apply Skip the rest of the form and sign bottom of form. IV No Go to Question 2. 2. Does your real property haI e a licensed plumber certifying that, due to the age or configuration of the property or its plumbing, installation of water -conserving plumbing fixtures is not technically feasible? ❑ Yes Civil Code Sections 1101 1 through 1101.8 do not apply ❑ The licensedliplumber's certification has been provided to the Building Division. Skip the rest of the form and sign bottom of form. CSI No Go to Question 3 3 Is water service permanently disconnected for your building? ❑ Yes Civil Code Sections 1101 1 through 1101.8 do not apply Skip the rest of the form and sign bottom of form. V No Go to Question 4 4 Is your real property built i d available for use or occupancy on or before January 1, 1994? ❑ No My real property is built and available for use or occupancy after January 1, 1994 Civil Code Sections 1101 1 through 1101.8 do not apply Skip the rest of the form and sign bottom of form. I/ Yes My real property, is built and available for use or occupancy on or before January 1, 1994 Civil Code Sections 1101 1 through 1101.8 apply Check one of the three following statements and sign bottom of form.. 11 Please check ONE of the following: S1 My property is a single-family residential real property See Civil Code Section 11014 On and after January 1, 2014, building alterations or improvements shall require all non-compliant plumbing fixtures to be replaced with water -conserving plumbing fixtures throughout the building. On or before January 1, 2017, all non- compliant plumbing fixtures shall be replaced with water -conserving plumbing fixtures (regardless of whether property undergoes alterations or improvements). ❑ My property is a multifamily residential real property See Civil Code Section 1101.5 On and after January 1, 2014, specified building alterations or improvements shall require non- compliant plumbing fixtures to be replaced with water -conserving plumbing fixtures. On or before January 1, 2019, all non-compliant.plumbing fixtures shall be replaced with water - conserving plumbing fixtures throughout the building (regardless of whether property undergoes alterations or improvements). i r, ' ❑ My property is a commercial real property Sed -Civil Code Section 1101.5 On and after January 1, 2014, specified building alterations or improvements shall require non- compliant plumbing fixtures to be replaced with water -conserving plumbing fixtures. On or before January ll, 2019, all non-compliant plumbing fixtures shall be replaced with water- conserving plumbing fixtures throughout the building (regardless of whether property undergoes alterations or improvements). I, as the owner or owner's agent of this property, certify under penalty of perjury that non-compliant plumbing fixtures will be replaced prior to date specified above with water -conserving plumbing fixtures in accordance with Civil Code Sections 1101 1 through 11018, the current California Plumbing Code and California Green Building Standards Code, and manufacturer's installation requirements, and that the water -conserving plumbing fixtures comply with the requirements as indicated in the table on the following nage.', Owner or Owner Agent's Signature. Date. 11116116 1 Upon completing and signing this Certificate, please return it to the Building Division in order to final your building permit. SB407 2015 doc revised 08126/15 -.e by tALGREEN RESIDENTIAL CHECKLIST MANDATORY: :ITEMS COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION CUF RTI NC3 : ALBERT* SALVADOR, P:E., C.B.O., BUILDING OFFICIAL 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 `(408) 777-3228 • FAX (408) 777-3333 • building(ckul2ertino.org PURPOSE; The 2013 CalGreen Code applies to additions or alterations of exisingrresident� buil 3irigs where the addition alteration increases the building`s conditioned area, volume=, or size and also � to all new low-riseents that or n im rovem residential buildings, high-rise residential buildings, or both. existing site and land a g p are not otherwise' disturbed are not subject to the requirements of CALGreen. A a #s FA A Project Name: c Project Address: Project Description:% NIf InstructionsjoB ALL p itis e � e te heCalifornia1,The Owneror the Owners agentt shall employ a licensed pro Im orkbGreen Building Standards Codes to verify and assure that alqu r d ork esenbe rein is properly planned and implemented in the project. „ 2. The licensed professional, in collaboration with the owner and the,rdesign professional shall initial Column 2 of this checklist, sign and date Section 1 - esr ra verification afi thepend,of thl- checklist and have the--=- P checklist printed on the approved plans for th �roctu;lr gin, D,rn, n t licensed professional shaJ c, mplete Column 3 3. Prior to final inspection by the Building Depart and sign a-nd date Section 2 - Implementatio �lerr# atio�y � #qe ec d� of this checidist and submit the completed f t 2`1 'Id'ng f s �ector. PIL R -VIEWED FOfO ,,. X1.)9 COMPLIANCE Revi6wea By. Column 2 Column 3 MANDATORY FEATURE OR MEASURE Project Verification Requirements 4.106.2 Storm water drainage and retention during construction. A plan is developed and implemented to manage storm water drainage during: construction. 4.106.3 Grading and paving. The site shall be Manned and developed to keep surface water away from buildings_ Construction plans shall indicate how site grading or a drainage system will manage all surface water flows. Page 1 flf, CaZGreen 2014 -doe revised 11104114' x in W 2 my. 4.201.1 Low-rise residential buildings shall meet or exceed the minimum ]"T-74, standard design required by the California Energy Standards. 4.303.1 Water conserving; plumbing fixtures and fittings. Plumbing fixtures (water closets and urinals) and fittings (faucets and showerheads) shall comply with the following: 'K 4.303.1.3.2 Water Closets. The effective flush volume of ail water closets shall not exceed 1.28 gallons per flush. Tank -type water clos--ts shall be certified to the performance criteria of the U.S. EPA WaterSense Specifications for Tank -type Toilets. 4.303.1.3.2 Urinals. The effective flush volume of urinals shall not exceed 0.5 gallons per flush. 4.303.1.3.1 Single Showerheads: Showerheads shall have a maximum flow rate of not more than 2.0 gallons per minute at 80 psi. Showerheads shall be certified to the performance criteria of the U -S. EPA WaterSense Specification for showerheads. 4.303.1.3.2 Multiple Showerheads serving one shower. When a shower is served by more than one showerhead, the combined flow rate of all showerheads and/or other shower outlets controlled by a single valve r� a shall not exceed 2.0 gallons per minute at 80 psi, or the shower shall be ] °❑' f designed to allow only one shower outlet to be in operation at a time. 4.303.1.4.1 Residential lavatory faucets. The maximum flow rate of residential lavatory faucets shall not exceed 1.5 gallons per minute at 60 psi'. The minimum flow rate of residential lavatory faucets shall not be less than 0.8 gallons per minute at 20 psi. 4.303.1.3.2 Lavatory faucets in common and public use areas. The maximum flow rate of lavatory faucets installed in common and public use areas (outside of dwellings or sleeping units) in residential buildings shall not exceed 0.5 gallons per minute at 60 psi. ❑ 4.303.1.4.3 Metering faucets. Metering faucets when installed in. residential buildings shall not deliver more than 0.25 gallons per cycle. 4.303.1.4.4 Kitchen Faucets. The maximum flow rate of kitchen faucets shall not exceed 1.8 gallons per minute at 60 psi. Kitchen faucets may temporarily increase the flow above the maximum rate, but not to exceed 2.2 gallons per minute at 60 psi, and must default to a maximum flow rate of 1.8 gallons per minute at 60 psi. 4.303.2Standards for plumbing fixtures and fittings. Plumbing fixtures and fittings shall be installed in accordance with the California Plumbing Code, and shall meet the applicable standards referenced in Table 1401.1 of the California Plumbing Code. CalGreen 2014.doc reviser/ 11/04114 Page 2 of 5 4.304.1 Irrigation controllers. Automatic irrigation systems installed at the time of final inspection shall be weather -based - 4.304 -1.1 Controllers shall be weather- or soil moisture -based controllers that automatically adjust irrigation in response to changes in plants' needs as weather conditions change. —o 4.304.1.2 Weather -based controllers without integral rain sensors or communication systems that account for local rainfall shall have a separate wired or wireless rain sensor which connects or communicated with the controiier(s). Soil moisture -based controllers are not required to have rain sensor input. 4.406.1 Rodent proofing. Annular spaces aroundpipes, electric cables conduits, or other openings in plates at exterior walls shall be protected against the passage of rodents by closing such openings with cement mortar, -`-Z concrete masonry or similar method acceptable to the enforcing agency, 4.408.2 Construction waste management plan. Where a local jurisdiction does not have a construction and demolition waste management ordinance, a construction waste management plan shall be submitted for approval to the enforcing agency. 4.410.1 Operation and maintenance manual. At the time of final inspection, an operation and maintenance manual shall be provided to the building occupant or owner. 4.503.1 General. Install only a direct -vent sealed -combustion gas or sealed wood -burning fireplace, or a sealed woodstove. 4.504.1 Covering of duct openiings and protection of mechanical equipment during construction. Duct openings and other related air distribution component openings shall be coveredduring construction. 4.504.2.1 Adhesives, sealants and caulks.- Adhesives, sealants and caulks shall be compliant with VOC and other toxic compound limits:. 4.504.2.2 Paints and coatings. Paints, stains and other coatings shall be compliant with VOC limits. A—z 4.504.2.3 Aerosol paints and coatings. Aerosol paints and other coatings shall be compliant with product, weighted MIR Limits for ROC and other toxic A—Z compounds. Page 3 of 5 - CalGreen 2014. doe revised 11104114 4.504.2.4 Verification. Documentation shall be provided to verify that compliant VOC limit finish materials have been used. 4.504.3 Carpet Systems. Carpet and carpet systems shall be compliant with VOC limits. 4.504.4 Resilient flooring systems. Eighty (80) percent of floor area receiving resilient flooring shall comply with the VOC-emission limits defined in the Collaborative for High Performance Schools (CHPS) Low -emitting Materials List or be certifiedunder the Resilient Floor Covering Institute (RCFI) FtoorScore program. 4.504,5 Composite wood products. Particleboard, medium density fiberboard (MDF), and hardwood plywood used in interior finish systems shall comply low A—( with formaldehyde emission standards. Ipteiri Mols#iure C i'l . 4.505.2 Concrete slab foundation. Required vapor retarders and capillary breaks are also required to comply with CalGreen Section 4.505.2.1. — i 4.505.3 Moisture content of building materials. Moisture content of building materials used in wall and floor framing is checked before enclosure. "' e , Iricloor Air Qua[�fy and" Exhaust ., 4.506.1 Bathroom exhaust fans. Exhaust fans which terminate outside the building are provided in every bathroom. —2 Ernvirorirnental Comfort 4.507.2. Duct systems are sized and designed and equipment is selected using the following methods: 1- Establish heat loss and heat gain values according to RCCA Manual J or equivalent. ~ t 2. Size duct systems according to ACOA 29-D (Manual D) or equivalent. 3. Select heating and cooling equipment according to ACOA 36-S (Manual S) or equivalent. INSTALLER , ! • QUALIFICATIONS b�u�hfircatcon .. c 742.1 Installer training. HVAC system installers are trained and certified in the proper installation of HVAC systems. �/ rt Laud 702.2 Special inspection. The Licensed Professional responsible to verify CALGreen compliance is qualified and able to demonstrate competence in the — discipline they inspect and verify. l�er`rficatitns 703.1 Documentation. Verification of compliance with CALGreen may include construction documents, plans, specifications, builder or installer certification, inspection reports, or other methods acceptable to the enforcing agency which show EJ A -c substantial conformance. Implementation verification shalt be submitted to the Building Department after implementation of all required measures and prior to final inspection approval.. Page 4 of 5 CalGreen 2014.. doe revised 11104114 Project Narne: Project Address: Project Description: CALGREEN SIGNATURE DECLARATIONS ECTION 1 - DESIGN VERIFICATION Complete all lines of Section 1 `Design Verification and submit the completed checklist (Columns 1 and 2) with the plans and building permit application to the Building Department. The owner and design professional responsible for compliance with CalGreen Standards have revised the plans and certify that the items checked above are hereby incorporated into the project plans and will be implemented into the project in accordance with the requirements set forth in the 2013 California Green Building Standards Code as adopted by the City of Cupertino, Owner's Signature Owner's Name (Please Print) C/L4 Design Professiona Signa re Print) Signature of Licens rofe sional responsible for CalGreen compliance Ha HG$,$,�— k-71 in 0 ®i &t Name of LLiic//e��nse Proff§5 N ional responsible for CalGreen compliance (Please Print) Email Address for Professional responsible for CalGreen compliance yf ?/Z -DI. Date D e Apr - ~z Date (404 -83-fq Phone SECTION 2 - IMPLEMENTATION VERIFICATION Complete, sign and submit the competed checklist, including column 3; together withal[ original signatures on Section 2 to the Building -Department -prior to Building Department final inspection. I have inspected the work and have received sufficient documentation to ver-ify "aifd certify -that the -project, identified above was constructed in accordance with this Green Building Checklist and in accordance with the requirements cfy th 2.13 California GFeen Buildin Standards Code. -as adopted by the City of Cupertino. r Si(gnatur�ej off License Professi na responsible for CalGreen compliance pat Name of Licensee Professional responsible for CalGreen compliance (Please Print) Phone Address for License' rofessional responsible for calGreen compliance Page 5 of 5 CalGreen 2014 doe revised 11104114 �i CUPERTINO OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildinona cuoertino.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- //0,6 PgRg C orazrjob• ..... " cA 9si 1 APIC OWNER NA iE M �rtr I � .rum . .. _ OWNER ADDRESS- DDRESS . C ✓' Ir -7 il�i1 9Q'� DESCRIPTION OF WORK: ArD i tiOIJ DESCRIPTIO _ 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.) M J1. I 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 icjuries. I am willfully acting as an Owner -Builder and am aware of the limits of my insurance coverage for inj0ries to workers on my property. tkS 2. 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. MS 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. MS 4.1 understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. MS 5.1 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. N16. 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. fy9 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. 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. OwnerBudderForm 2010.doc revised 04/14/10 1 VS 9 I understand I m2v ohtnin more information renardinn my ohlin2tions 2s an "emolover" 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 (2782) or wvrw.cslb.ca.gov for more information about licensed contractors. W10. I 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. 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. K 12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information l 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 maybe 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.) I 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 siqnature. Property Owner's Signature: Date: %/P/2-0 ---------------------------------------------------7-------------------------------I----------------------I---------------------------------- (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 I 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. OwnerBuilderForm 2010.doc revised 04/14/10 w CALGREEN RESIDENTIAL CHECKLIST - MANDATORY ITEMS COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION CUPERTINO ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL 10300 TORRE AVENUE • CUPERTINO, CA 95014-32Sr5 COPN (408) 777-3228 • FAX (408) 777-3333 - build' e �� PURPOSE: The 2013 CalGreen Code applies to additions or alterations of existing residential buildings where the addition or alteration increases the building's conditioned area, volume, or size and also applies to all new low-rise residential buildings, high-rise residential buildings, or both. Existing site and landscaping improvements that are not otherwise disturbed are not subject to the requirements of CALGreen. Project Name: Wa kXqQ(�c 7ilvL iSICtC.� �L�bi-+ tA IL ---------------- Project Address: C) to pz-6 u 5 hM Ye 1r •yiye, Project Description: 8UBMITTAL Instructions: #2 1 . The Owner or the Owner's agent shall employ a licensed professional experienced with the California Green Building Standards Codes to verify and assure that all required work described herein is properly planned and implemented in the project. 2. The licensed professional, in collaboration with the owner and the desjgNR'r essional shall initial Column 2 of this checklist, sign and date Section 1;- Design Verificatiss.on,}�aw}}}}.,+�1pT� sp ttI� checklist and have the >JU�II.eIIiJ'�::�fJ4 �11:.'ll� checklist printed on the approved plans for the project. 3. Prior to final inspection by the Building Department, the licensed professional shall complete Column 3 and sign and date Section 2 - Implementation Verification at the end of this checklist and submit the completed form to the Building Inspector. REVIEWED I:UMPLIANCE Reviewea by /75/1 / MANDATORY FEATURE OR MEASURE Planning and Design - Site Development 4.106.2 Storm water drainage and retention during construction. A plan is developed and implemented to manage storm water drainage during construction. 4.106.3 Grading and paving. The site shall be planned and developed to keep surface water away from buildings. Construction plans shall indicate how site grading or a drainage system will manage all surface water flows. Column 2 Project Reauirements i4 ,4 Column 3 Verification ❑ A -v Page 1 of 5 CalGreen 2014.doc revised 11104114 A4.2 General 4.201.1 Low-rise residential buildings shall meet or exceed the minimum standard design required by the California Energy Standards. A4.3 WATER EFFICIENCY AND CONSERVATION Indoor Water Use 4.303.1 Water conserving plumbing fixtures and fittings. Plumbing fixtures (water closets and urinals) and fittings (faucets and showerheads) shall comply with the following: 4.303.1.3.2 Water Closets. The effective flush volume of all water closets shall not exceed 1.28 gallons per flush. Tank -type water closets shall be certified to the performance criteria of the U.S. EPA WaterSense Specifications for Tank -type Toilets. ❑ 4.303.1.3.2 Urinals. The effective flush volume of urinals shall not exceed 0.5 gallons per flush. 4.303.1.3.1 Single Showerheads. Showerheads shall have a maximum flow rate of not more than 2.0 gallons per minute at 80 psi. Showerheads shall be certified to the performance criteria of the U.S. EPA WaterSense Specification for showerheads. ❑ 4.303.1.3.2 Multiple Showerheads serving one shower. When a shower is served by more than one showerhead, the combined flow rate of all showerheads and/or other shower outlets controlled by a single valve shall not exceed 2.0 gallons per minute at 80 psi, or the shower shall be designed to allow only one shower outlet to be in operation at a time. 4.303.1.4.1 Residential lavatory faucets. The maximum flow rate of residential lavatory faucets shall not exceed 1.5 gallons per minute at 60 psi. The minimum flow rate of residential lavatory faucets shall not be less than 0.8 gallons per minute at 20 psi. ❑ 4.303.1.3.2 Lavatory faucets in common and public use areas. The maximum flow rate of lavatory faucets installed in common and public use areas (outside of dwellings or sleeping units) in residential buildings shall not exceed 0.5 gallons per minute at 60 psi. ❑ 4.303.1.4.3 Metering faucets. Metering faucets when installed in residential buildings shall not deliver more than 0.25 gallons per cycle. 4.303.1.4.4 Kitchen Faucets. The maximum flow rate of kitchen faucets shall not exceed 1.8 gallons per minute at 60 psi. Kitchen faucets may temporarily increase the flow above the maximum rate, but not to exceed 2.2 gallons per minute at 60 psi, and must default to a maximum flow rate of 1.8 gallons per minute at 60 psi. 4.303.2 Standards for plumbing fixtures and fittings. Plumbing fixtures and fittings shall be installed in accordance with the California Plumbing Code, and shall meet the applicable standards referenced in Table 1401.1 of the California Plumbing Code. Page 2 of 5 CalGreen 2014.doc revised 11104114 -T.-z-4 A -z A-2 Outdoor Water Use 4.304.1 Irrigation controllers. Automatic irrigation systems installed at the time of final inspection shall be weather -based. 4.304.1.1 Controllers shall be weather- or soil moisture -based controllers that automatically adjust irrigation in response to changes in plants' needs as weather conditions change. �j !�! ❑ 4.304.1.2 Weather -based controllers without integral rain sensors or communication systems that account for local rainfall shall have a separate wired or wireless rain sensor which connects or communicated with the controller(s). Soil moisture -based controllers are not required to have rain sensor input. .. .4 MATERIAL CONSERVATION AND RESOURCE EFFICIENCY Enhanced Durability and Reduced Maintenance 4.406.1 Rodent proofing. Annular spaces around pipes, electric cables, conduits, or other openings in plates at exterior walls shall be protected ❑ against the passage of rodents by closing such openings with cement mortar, concrete masonry or similar method acceptable to the enforcing agency. Construction Waste Reduction, Disposal and Recycling 4.408.2 Construction waste management plan. Where a local jurisdiction does not have a construction and demolition waste management ordinance, a tvti 1�1 ❑ construction waste management plan shall be submitted for approval to the enforcing agency. Building Maintenance and Operation 4.410.1 Operation and maintenance manual. At the time of final inspection, an operation and maintenance manual shall be provided to the building ❑ occupant or owner. A4.5 ENVIRONMENTAL Fireplaces 4.503.1 General. Install only a direct -vent sealed -combustion gas or sealed Elwood -burning fireplace, or a sealed woodstove. Pollutant Control 4.504.1 Covering of duct openings and protection of mechanical equipment during construction. Duct openings and other related air ❑ distribution component openings shall be covered during construction. 4.504.2.1 Adhesives, sealants and caulks. Adhesives, sealants and caulks Cpl LCI ❑ shall be compliant with VOC and other toxic compound limits. 4.504.2.2 Paints and coatings. Paints, stains and other coatings shall be ❑ compliant with VOC limits. 4.604.2.3 Aerosol paints and coatings. Aerosol paints and other coatings ❑ shall be compliant with product. weighted MIR Limits for ROC and other toxic compounds. Page 3 of 5 CalGreen 2014.doc revised 11104114 A -v A -Z A -c A -o A -z A -Z A -Z 4.504.2.4 Verification. Documentation shall be provided to verify that �I ILEI 11compliant VCC limit finish materials have been used. 4.504.3 Carpet Systems. Carpet and carpet systems shall be compliant with ❑ ❑ VOC limits. 4.604.4 Resilient flooring systems. Eighty (80) percent of floor area receiving resilient flooring shall comply with the VOC-emission limits defined in the Collaborative for High Performance Schools (CHPS) Low -emitting Will ❑ Materials List or be certified under the Resilient Floor Covering Institute (RCFI) FloorScore program. 4.504.5 Composite wood products. Particleboard, medium density fiberboard (MDF), and hardwood plywood used in interior finish systems shall ❑ comply with low formaldehyde emission standards. Interior Moisture Control 4.505.2 Concrete slab foundation. Required vapor retarders and capillary ❑ breaks are also required to comply with CalGreen Section 4.505.2.1. 4.506.3 Moisture content of building materials. Moisture content of building ❑ materials used in wall and floor framing is checked before enclosure. Indoor Air Quality and Exhaust 4.506.1 Bathroom exhaust fans. Exhaust fans which terminate outside the �v5 �I ❑ building are provided in every bathroom. Environmental Comfort 4.607.2. Duct systems are sized and designed and equipment is selected using the following methods: 1. Establish heat loss and heat gain values according to ACCA Manual J or equivalent. ❑ 2. Size duct systems according to ACCA 29-D (Manual D) or equivalent. 3. Select heating and cooling equipment according to ACCA 36-S (Manual S) or equivalent. INSTALLER AND SPECIAL INSPECTOR QUALIFICATIONS Qualifications 702.1 Installer training. HVAC system installers are trained and certified in c�i LSI ❑ the proper installation of HVAC systems. 702.2 Special inspection. The Licensed Professional responsible to verify CALGreen compliance is qualified and able to demonstrate competence in the ❑ discipline they inspect and verify. Verifications 703.1 Documentation. Verification of compliance with CALGreen may include construction documents, plans, specifications, builder or installer certification, inspection reports, or other methods acceptable to the enforcing L^J ❑ agency which show substantial conformance. Implementation verification shall be submitted to the Building Department after implementation of all required measures and prior to final inspection approval. Page 4 of 5 CalGreen 2014.doc revised 11/04114 4-Z FAW A -Z S-0 A -z - A -Z A_Z A-0 A-V Project Name: Project Address: Project Description: CALGREEN SIGNATURE DECLARATIONS (-tiVl Sl lYL S l"LCJL Actdl i n -L, l l CT?r? Ue SECTION 1 - DESIGN VERIFICATION Complete all lines of Section 1 — "Design Verification" and submit the completed checklist (Columns 1 and 2) with the plans and building permit application to the Building Department. The owner and design professional responsible for compliance with CalGreen Standards have revised the plans and certify that the items checked above are hereby incorporated into the project plans and will be implemented into the project in accordance with the requirements set forth in the 2013 California Green Building Standards Code as adopted by the City of Cupertino. 4 ZO/ Owner's Sig4ture Date NA -T l Owner's Name (Please Print) %(— Ceas�c 17,u Design Professiona Signa re D e ii- L VLC' �GLFy Design Professional's N e (Please Print) /� L I A Signature of Licens rofe sional responsible for CalGreen compliance Date a c- 1 4c� Njjame of License Prof Tonal responsible for CalGreen compliance (Please Print) Phone kCLLt C,rLQCv CZV I -CC--�l Email Address for cense Professional responsible for CalGreen compliance SECTION 2 - IMPLEMENTATION VERIFICATION Complete, sign and submit the competed checklist, including column 3, together with all original signatures on Section 2 to the Building Department prior to Building Department final inspection. I have inspected the work and have received sufficient documentation to verify and certify that the project identified above was constructed in accordance with this Green Building Checklist and in accordance with the requirements of the 2013 California Green Building Standards Code as adopted by the City of Cupertino. Signature of License Professional responsible for CalGreen compliance Date Name of License Professional responsible for CalGreen compliance (Please Print) Phone Email Address for License Professional responsible for CalGreen compliance Page 5 of 5 CalGreen 2014.doc revised 11104114