15090103CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10362 JUDY AVE
CONTRACTOR: MIKE COUNSIL
PERMIT NO: 15090103
PLUMBING INC
OWNER'S NAME: RABY MARY E TRUSTEE
1915 O'TOOLE WAY
DATE ISSUED: 09/16/2015
OWNER'S PHONE: 4086459451
SAN JOSE, CA 95131
PHONE NO: (408) 2724900
LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
INSTALL (N) GAS SAFETY SHUT OFF VALVE AT METER &
—I
REPLACE GAS LINES THROUGHOUT SFD
LicenseClass 10 Lic. # 1 1p
1 'Zfl JS
—�— Date
Contracgingwit
I hereb affirmt I am licensed under the provisions of Chapter 9
(commSection 7000) of Division 3 of the Business & Professions
Code aicense is in full force and effect.
Sq. Ft Floor Area:
Valuation: $26290
I hereby affirm under penalty of perjury one of the following two declarations:
i. I have and will maintain a certificate of consent to self -insure for Worker's
APN Number: 37510006.00
Occupancy Type:
Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
2. a 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
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
180 DAYS ST ED 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 cit�to nterupon
the above mentioned property for inspection purposes. (We) agree
Date:
indemnify and keep harmless the City of Cupertino against liabilities,jue
costs, and expenses which may accrue against said City in consequence e
peit. Additionally, the applicant understands and will comply with
granting of' rm
RE -ROOFS:
all non-poin so rce regulations per the Cuperti unicipal Cde, Sect' n 9.18.
All roofs shall be inspected prior to any roofing material being installed. If a roof is
Signature Dated
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
Signature of Applicant: Date:
❑ O lk-BUILDER DECLARATION
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. 1 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
i. 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
Health & Safety Code, Sections 25505, 25533, and 25534.
performance of the work for which this permit is issued.
2. I have and will maintain Worker's Compensation Insurance, as provided for by
Ow er o uthorized agent: /
Section 3700 of the Labor Code, for the performance of the work for which this
Date:
permit is issued.
3. I certify that in the performance of the work for which this permit is issued, I shall
CONSTRUCTION LENDING AGENCY
not employ any person in any manner so as to become subject to the Worker's
that there is a construction lending agency for the performance of work's
Gereb�ys
Compensation laws of California. If, after making this certificate of exemption, I
permit is issued (Sec. 3097, Civ C.)
become subject to the Worker's Compensation provisions of the Labor Code, I
Ls
Lender's Name
must forthwith comply with such provisions or this permit shall be deemed
revoked.
Lender's Address
APPLICANT CERTIFICATION
ARCHITECT'S DECLARATION
I certify that I have read this application and state that the above information is
I understand my plans shall be used as public records.
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
Licensed Professional
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply with
all non -point source regulations per the Cupertino Municipal Code, Section 9.18.
Signature Date
CUPERTINO
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 950143255 AISC (408) 777-3228 •FAX (408) 777-3333 • buildinaCo7cupertino.ora /�� )
LUAIBING ❑MECHANICAL ❑ELECTRICAL []MISCELLANEOUS
PRCJ-r.CTADDRESS 2( Z JLA A A U -j -�-5
7 I O - OO
ONVN1R NAME PHONE
g �O� S I OS I I E-M4II
STREET ADDRESS Q r UL 1 j� 1 , CITY LTATE, ZIP A 1 /\ n w SC r FAX -
-�V f21
PHONEE-MAIL
COI3TACT NAME �1 l v
L 0 9 A t q
STREET DRESS 1
rn [tib o r+ 7 e-
CITY, STATE, ZIP
FAX
❑ OHT:1t ❑ ORR.'ER-BUILDER ❑ Ott^N'ERAGal,T CONTRACTOR ❑ CONTRACTOR.AGENT ❑ ARCH=,CT ❑ ENGINEER. ❑ DEVELOPER ❑ T=N.tT?
CONTRACTORN4TIE\_ I LICENSENUMBER n�) I LICENSE TYPE
`J L (- 'O
BUS. LIC
COMPANY NAME
E-MAIL
FAX
STRE ADD S
Cil5 0400ock-ar
C13,STATE, Z1P
Sone c i3 1
PHONE
WA 2 1-ycfv�
A RCHITECT/ENGTNEER NAME LICENSE NUMBER
BUS. LIC ;-
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE-
HONEUSE
USEOF WIFE, or DUPI-EX ❑ MULTI-FA1,1ILY I . PROJECT IN WD-DLANT ❑ 'as PROTECT IN ❑ YES
BUII-DA'G: ❑ COb-L\=CLAL URBAN II.'TERFACE AREA ❑ NO FLOOD ZONE ❑ NO
IS THE BLDG AN ❑ ':-ES
EICHLER HOME? ❑ NO
DESCRIPTION OF WORK i
sYl !;14 'OL , ��, r-�-L.
9 o '? 74
TOTAL VALUATION: �' 2
6 / �7 C- q ,
By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the propertya . 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 ' ding - construction. I authorize representatives of Cupertino to enter the a��biiove identi d property for inspection purposes.
Signature of Applicant/Agent: Date:
STJP IENTAL INFORMATION REQUIRED
�..
OFT IICE USE ONLY
L" ,.
kfEPAlisc.4pp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
19
ADDRESS: 10362 JUDY AVE
DATE: 09/16/2015
REVIEWED BY: MELISSA
UNITS
APN: 37510 006
BP#:
*VALUATION: 1$26,290
°PERMIT TYPE: Plumbing Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY SFD or Duplex
USE:
#
PENTAMATION 1 RPGAS
I PERMIT TYPE:
WORK
INSTALL N SAFETY SHUT OFF & REPLACE GAS LINES THROUGHOUT SFD
SCOPE
SuppL Insp Fee
APPLIANCE / EQUIP TYPE
FEE ID
Plumb. Plan Check 1 0.0 Fhrs $0.00
QTY
UNITS
BP FEES
Flec. Pei-nTit Fe,
Piping, Gas >4 Outlets
1BPGAS
! )ther Elec. lust,
6
#
$432
Piping, Floor
1PREPPIPE
SuppL Insp Fee
1
#
$48
PME Unit Fee:
$480.00
PME Permit Fee:
$48.00
Con,SIruelion Tax:
T
_r
Administrative Fee: IADMIN
$45.00
Work Without Permit? 0 Yes (F) No
$0.00
TOTALS:
Travel Documentation Fee: ITRA VDOC
$480.00
Strong Motion Fee: IBSEISMICR
NOTE: This estimate does not include fees due to other Departments (i.e. 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 Dept for addn7 info.
FEE ITEMS (Fee Resolution 11-033 Ef: 7f 11113)
11ech. Placa Check
Plumb. Plan Check 1 0.0 Fhrs $0.00
!Jec. Plan Check
Wech. Permit 1 ee:
Plumb. Permit Fee: IPPERMIT
Flec. Pei-nTit Fe,
Other alcch. /rasp.ET-L-
Other Plumb Insp. E:O]—;;s $48.00
! )ther Elec. lust,
Alech. Insp. Fee:
PME Plan Check:
Elee. Imp. Fee:
NOTE: This estimate does not include fees due to other Departments (i.e. 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 Dept for addn7 info.
FEE ITEMS (Fee Resolution 11-033 Ef: 7f 11113)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
Suppl. PC Fee
PME Plan Check:
$0.00
Permit Fee:
SuppL Insp Fee
PME Unit Fee:
$480.00
PME Permit Fee:
$48.00
Con,SIruelion Tax:
T
_r
Administrative Fee: IADMIN
$45.00
Work Without Permit? 0 Yes (F) No
$0.00
,IrIvanced Planning Fees:
Travel Documentation Fee: ITRA VDOC
$48.00
Strong Motion Fee: IBSEISMICR
$3.42
Select an Administrative Item
Bldjz Stds Commission Fee: IBCBSC
$2.00
SUBTOTALS:
T$626.421
$0.00 TOTAL FEE:
1 $626.42
Revised: 07/02/2015
BUILDING PERMIT CANNOT BE FINALED AND COAIPLETED UNTIL THIS
CERTIFICATE HAS BEEN SIGNED AND RETURNED TO THE BUILDING DIVISION
1. If the existing plumbing fixture water usage/flow rate is equal to or lower than the figure shown, it is not required to be upgraded.
SB4072015.docremised 08126115
Non -Compliant
Water -Conserving Plumbing Fixture
Plumbing Fixture/
(Fixture Complying with Current Code Applicable to New Construction)
Maximum Water Usage/Flow Rate
Fixture Type
Water Usage
2013 CPC Ch. 4
2013 CPC Ch. 4
2013 CPC Ch. 4
/Flow Rate
2013 CALGreen Div. 4.3
2013 CALGreen Div. 4.3
2013 CALGreen Div. 5.3
Single -Family
Multi -Family
Commercial
Residential
Residential
Water Closets
Exceed 1.6
Single flush toilets: 1.28 gallons/flush
(Toilets)
Gallons/flush
Dual flush toilets: 1.28 gallons/flush effective flush volume (the composite,
average flush volume of two reduced flushes and one full flush
Urinals
Exceed 1.0
Gallons/flush
0.5 gallons/flush
Showerheads
Exceed 2.5
2.0 gallons per minute @ 80 psi. Also certified to the performance criteria of
gallons per minute
U.S. EPA WaterSense Specification for Showerheads
(A hand-held shower is considered a showerhead.)
For multiple showerheads serving one shower, 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 @ 80 psi, or the shower shall be designed to
allow only one shower outlet to be in operation at a time.
Faucets —
Exceed 2.2 gallons
Maximum 1.5 gallons per
Within units:
0.5 gallons per minute @ 60
Lavatory
per minute
minute @ 60 psi; minimum
Maximum 1.5 gallons
psi
Faucets
0.8 gallons per minute @
per minute @ 60 psi;
20 psi
minimum 0.8 gallons
per minute @ 20 psi
In common and public
use areas: 0.5 gallons
per minute @ 60 psi
1.8 gallons per minute
60 psi
Faucets —
Exceed 2.2 gallons
1.8 gallons per minute @
1.8 gallons per minute
1.8 gallons per minute @ 60
Kitchen
per minute
60 psi
@ 60 psi
psi
Faucets
May temporarily increase
May temporarily
up to 2.2 gallons per
increase up to 2.2
minute @ 60 psi, and must
gallons per minute @
default to maximum
60 psi, and must
1.8 gallons per minute @
default to maximum
60 psi
1.8 gallons per minute
Where faucets meeting
@ 60 psi
the above are unavailable,
Where faucets meeting
aerators or other means
the above are
may be used to achieve
unavailable, aerators or
reduction.
other means may be
used to achieve
reduction.
1. If the existing plumbing fixture water usage/flow rate is equal to or lower than the figure shown, it is not required to be upgraded.
SB4072015.docremised 08126115
TILE
lo� -ty 7-
CERTIFICATE OF VERIFICATION
CF3R-MCH-22-H
Space Conditioning System Fan Efficacy
(Pa of,
Project Name:
Enforcement Agency: City of
Permit Number:
15090103
- '
Cupertino
02
System Location or Area Served
Dwelling Address: 10362 JudyAvenue
City:. Cupertino
Zip Code:
95014
i
A. Ducted Cooling Syste nform '
01
Actual Tested Watts
580
01
System Identification or Name
1070
System 1
Required Fan Efficacy (watts/cfm)
0.58
02
System Location or Area Served
0.54
Whole House
Compliance Statement:
System fan efficacy complies
03
System Installation Type
Replacement
04
Nominal Cooling Capacity (tons) of Condenser
3
05
Condenser Speed Type.-',,,
Single Speed
06
Cooling System Zonal*tdfitrol Type
Not Zonal
07
}
Central Fan Integrated (CFI) Ventilation System.,Status--
Not a CFI system
08
System Bypass Duet Status 3
s
No Bypass Duct r }t r
P }
.i'• ..l :'i _- .n. ... : :, . e e}
i. ...i
F :.
r.,,.. S..N. 1..e.
_
1,. hx'.,...:.�
c
ii; f. `:.
09
Date of SystemrAirflow Rate Measurement015-08-17
r30_
`",ow,rate?measurement
Airflow Rate Protocol utilized _
RA3 3 pr..ocedures
for airfl
.
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 1 Fan Watt Verification Device Used.
Portable watt meter
MCH -22a Forced Air System Fan Efficacy Measurement - Newly Installed Non -Zoned Systems or Zoned Multi -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
580
02
Actual Tested Airflow from MCH -23 (cfm)
1070
03
Required Fan Efficacy (watts/cfm)
0.58
04
Actual Fan Efficacy (watts/cfm)
0.54
05
Compliance Statement:
System fan efficacy complies
Registration Number: 215-A0211117A-M2200002A-M22A Registration Date/Time: 2015-10-22 12:31:46 HERS Provider: CaICERTS
CA Building Energy Efficiency Standards Report Version: 2013-1.006 Report Generated: 2015-10-22 12:31:13
2013 Residential Compliance Schema Version: 0.51SDD
CERTIFICATE OF VERIFICATION CF3R-MCH-22-H
Space Conditioning System Fan Efficacy (Page 2 of 3 )
D. Additional Requirements
01
All registers were fully open during the diagnostic test.
02
System fan was set at maximum speed during the diagnostic test.
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 tested value.
Multi -speed compressor space cooling systems or variable speed compressor systems shall verify air flow (cfm/ton) and fan
05
efficacy (Watt/cfm) with system operating in cooling mode at the maximum compressor speed and the maximum air
handler fan speed.
Zoned cooling air distribution systems with single speed compressors shall meet both the airflow (cfm/ton) and fan efficacy
06
(Watt/cfm) criteria in every zonal control mode.
07
Verification Status
Pass - all applicable requirements are met
08
Correction Notes,. '
The responsible persons signature,oWthis compliance documentt affirms that all-appl.icable_requirements in this table have
been met unless otherwise noted in the Verification $tatus and'.the Corrections; Notes in this table.
-j i
" • V
E. Determination of HERS Verification Compliance
All applicable sections of this docume ,,shall indicate compliance with the specified verification protocol r ei qu irem eats in order
for this Certificate of Verification as a whole to be determined to be in compliance.
01 1 Complies: All specified verification protocol requirements on this document are met.
Registration Number: 215-A0211117A-M2200002A-M22A Registration Date/Time: 2015-10-22 12:31:46 HERS Provider: CaICERTS
CA Building Energy Efficiency Standards Report Version: 2013-1.006 Report Generated: 2015-10-22 12:31:13
2013 Residential Compliance Schema Version: 0.51SDD
CERTIFICATE OF VERIFICATION CF3R-MCH-22-H
Space Conditioning System Fan Efficacy (Page 3 of 3 j
Documentation Author's Declaration Statement
1. 1 certify that this Certificate of Verification documentation is accurate and complete.
Documentation Author Name:
Documentation Author Signature: ��77 �
Xen
Ken Frazier
c7razier
Company:
Date Signed:
Golden State Energy Efficiency Services
2015-10-22 12:31:46
Address:
CEA/ HERS Certification Identification (if applicable):
1463 Circus Ct.
City/State/Zip:
Phone:
Turlock CA 95380
209-667-2164
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 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 ofthe Certificate(s).of iiistallat on.(CF2R) signed:and-sul mitted,by the persons) responsible for the
construction or installation conforms to the,requirements"specified on the Certificate(s) of Compliance (CF1R) approved by -the enforcement agency.
S. I will ensure that a registered copy,•of this Certificate of Venfication`shall be posted or made,availatile with Phe, building permit(s)issued for the
building, and made "available to the, enforcement agency for`all applicable inspections I understand that a.registe'red: copy of this' Certificate of ; .•
Verification is required to be'incluiled with the documentation the builder provides to the building owner at "occupancy.
Builder Or Installer Information As Shown On`Thetertificate Of In -
Company Name (Installing Subcontractor, General Contractor, or Builder/Owner):
CONVECTEK
Responsible Builder or Installer Name:
CSLB License:
Karl Hornung
953068
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:
Golden State Energy Efficiency Services
Responsible Rater Name:
Responsible Rater Signature: �RT �Z
Ken Frazier
cJCen c7 razier
Responsible Rater Certification Number w/ this HERS Provider:
Date Signed:
CC2005910
2015-10-22 12:31:46
Digitally signed by CaICERTS. This digital signature is provided in order to secure the content of this registered document and in noway implies Registration Provider
responsibility for the accuracy of the information.
Registration Number: 215-A0211117A-M2200002A-M22A Registration Date/Time: 2015-10-22 12:31:46 HERS Provider: CalCERTS
CA Building Energy Efficiency Standards Report Version: 2013-1.006 Report Generated: 2015-10-22 12:31:13
2013 Residential Compliance Schema Version: 0.515DD
CERTIFICATE OF VERIFICATION CF3R-MCH-20-H
Duct Leakage Diagnostic Test (Page 1 of 3 )
Project Name: Mary
Enforcement Agency: City of
Cupertino
Permit Number: 15090103
Dwelling Address: 10362 Judy Avenue
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
Whole House
03
Building Type from CF -111
Single family
04
Verified Low Leakage Ducts in Conditioned Space
(VLLDCS) Credit from CF111?
No, credit is not taken
05
Verified Low Leakage Air Handling Unit (VLLAHU) Credit
from CF1R?
No, credit is not taken
06
Duct System `Gompliance Category , :; -
Replacement using smoke test
MCH -20e -Sealing All Accessible Leaks using Smoke Test
B. Duct Leakage Diagnostic Test - -
01
Condenser Nominal Cooling Capacity (ton)
3
02
Heating Capacity (kBtu/h)
0
03
Conditioned Floor Area served by this HVAC system (ft2)
1323
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
Cooling system method
08
Measured AHUAirflow
This field or section is not applicable
09
Calculated Target Allowable Duct Leakage Rate (cfm)
72
10
Actual duct leakage rate from leakage test measurement
(cfm)
120
Registration Number: 215-A0211117A-M2000002A-M20A Registration Date/Time: 2015-10-22 12:31:45 HERS Provider: CaICERTS
CA Building Energy Efficiency Standards Report Version: 2013-1.006 Report Generated: 2015-10-22 12:30:24
2013 Residential Compliance Schema Version: 0.551SDD
CERTIFICATE OF VERIFICATION CF3R-MCH-20-H
Duct Leakage Diagnostic Test (Page 2 of 3 )
B. Duct Leakage Diagnostic Test
01
Compliance Statement: System passes using smoke test of an altered HVAC system in an existing building. No visible smoke
exits the accessible portions of the duct system. Smoke is only emanating from air -handling unit (AHU) cabinet and non
11
accessible portions of the duct system. Note - Accessible is defined as having access thereto, but which first may require
02
removal or opening of access panels, doors, or moving similar obstructions. If access to the ducts requires an object to be
demolished or deconstructed then sealing of those ducts is not required
12
Notes:
C. Additional Requirements for Compliance
01
System was tested in its normal operation condition. No temporary taping allowed.
Outside air (OA) ducts for Central Fan Integrated (CFI) ventilation systems, shall not be sealed/taped off during duct leakage
testing. CFI OA ducts that, utilize controlled motorized dampers, that open only when OA ventilation is required to meet
02
ASHRAE Standard 62:2; 'and close when OA ventilation is not required, may be configured to the closed position during duct
leakage testing.
03
All supply and.return register boots were -sealed to the drywall.
04
Buildingcavities'were not used as plenums or latform returns m lieu of ducts' ; C
p
05
If cloth backed tape was used t'was covered:with=Mastic and draw barttls '
06
All connection points between the air handler and'lhe-supply and return plenutms are°completely sealed.
If the system complies using the Smoke Test method, the smoke test was conducted in accordance with the requirements
07
of Reference Residential Appendix RA3.1.4.3.6. Systems that comply using smoke test shall not be included in sample
groups for HERS verification compliance.
08
Verification Status:
Pass - all applicable requirements are met
09
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 1 Complies: All specified verification protocol requirements on this document are met.
Registration Number: 215-A0211117A-M2000002A-M20A Registration Date/Time: 2015-10-22 12:31:45 HERS Provider: CaICERTS
CA Building Energy Efficiency Standards Report Version: 2013-1.006 Report Generated: 2015-10-22 12:30:24
2013 Residential Compliance Schema Version: 0.551SDD
CERTIFICATE OF VERIFICATION CF3R-MCH-20-H
Duct Leakage Diagnostic Test (Page 3 of 3 )
Documentation Author's Declaration Statement
1.1 certify that this Certificate of Verification documentation is accurate and complete.
Documentation Author Name:
Ken Frazier
Documentation Author Signature: ��TT
clCen LTrazier
Company:
Date Signed:
Golden State Energy Efficiency Services
2015-10-22 12:31:45
Address:
CEA/ HERS Certification Identification (if applicable):
1463 Circus Ct.
City/State/Zip:
Phone:
Turlock CA 95380
209-667-2164
Responsible Person's Declaration statement
I certify the following under penaltyyof,perjury, under the laws of the State of California:
1. The information provid6 6`h this Certificate of Verification is true and correct.
2. 1 am the certified HERSRater 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 th. a applicable requirements in Reference Appendices RA2, RA3, and the requirements
specified on'the Certificate of Compliance fog tthe building approved by the enforcement agency.
4. The information�reported on applicable`sections of the Certificate(s) of'Installat on'(CF2R) signed andfsubmitted by the person(s) responsible for the
construction or installation conforms to the requirements specified on�the Certificates) of Compliance (CF1R) approved by the enforcement'agency.
S. I will ensure that.a registered copy;,of this Certificate of Veti ication'shall be posted -,"or made available.with the building permits) issued for the
building and made'available to theenforcement agency for,alI applicable inspections IAunderstand that a.registered,;copy of;this Certificate of
Verification islrequired to be mduded with the documentation the builder provides to the building owner at occupancy
g.-.s,.,k,
Builder Or Installer Information As `Shown Orli' dtertif cate�Of Installation"
Company Name (Installing Subcontractor, General Contractor, or Builder/Owner):
CONVECTEK
Responsible Builder or Installer Name:
CSLB License:
Karl Hornung
953068
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:
Golden State Energy Efficiency Services
Responsible Rater Name:
Ken Frazier
Responsible Rater Signature: �7-
cXen clrazier
Responsible Rater Certification Number w/ this HERS Provider:
Date Signed:
CC2005910
2015-10-22 12:31:45
Digitally signed by CaICERTS. This digital signature is provided in order to secure the content of this registered document, and in noway implies Registration Provider
responsibility for the accuracy of the information.
Registration Number: 215-A0211117A-M2000002A-M20A Registration Date/Time: 2015-10-22 12:31:45 HERS Provider: CaICERTS
CA Building Energy Efficiency Standards Report Version: 2013-1.006 Report Generated: 2015-10-22 12:30:24
2013 Residential Compliance Schema Version: 0.551SDD
CERTIFICATE OF VERIFICATION CF3R-MCH-23-H
Space Conditioning System Airflow Rate (Page 1 of 4 )
Project Name: Mary
Enforcement Agency: City of
Cupertino
Permit Number: 15090103
Dwelling Address: 10362 Judy Avenue
City: Cupertino
Zip Code: 95014
A. Ducted Cooling System Information
Instrument Specifications are given in RA3.3.1.1, and system airflow rate measurement apparatus information is given
in RA3.3.2.
01
Airflow Rate Measurement Type used for this airflow rate
01
System Identification or Name
verification.
RA3.3.3.1.4
System 1
Manufacturer of Airflow Measurement Apparatus
02
System Location or Area Served
Model number of Airflow Measurement Apparatus
ACCUBALANCE
Whole House
Certification Status of the Airflow Measurement Apparatus
03
System Installation Type
Accuracy
http://www.energy.ca.gov/title24/equipment_Cert/ama_fas
Replacement
04
Nominal Cooling Capacity (tons) of Condenser
3
05
Condenser Speed T e'�'t
p yp
Single Speed
06
Cooling System Zona!'Control Type
Not Zonal
07
Centra l'Fan Integrated(CFI)`Veritilation'System:Status —
Not a CFI system
08
v
r
System Bypass Duct Status r s
;
No Bypass Ductr s
A ��
yam. a'i.�
(1 i
7:h: .t,. ..i.".. .• 1 k`: `v..
l.i t"
09
Date of System 'Airflow`Rate Measurement
2015-08-17
i,
10
Airflow Rate Protocol utilized 'i
f 47
,RA3.3 procedures for airflow;rate measurement fi
B. Hole for the placement of a Static Pressure Probe (HSPP), and Permanently installed Static Pressure Probe (PSPP)
in the supply plenum.
Procedures for installing HSPP or PSPP are specified in RA3.3.1.1.
01 I Method used to demonstrate compliance with theI HSPP installed and labeled consistent with Figure RA3.3-1
HSPP/PSPP requirement
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.
01
Airflow Rate Measurement Type used for this airflow rate
Traditional Flow Capture Hood according to procedure in
verification.
RA3.3.3.1.4
02
Manufacturer of Airflow Measurement Apparatus
TSI
03
Model number of Airflow Measurement Apparatus
ACCUBALANCE
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_Cert/ama_fas
/index.html
Registration Number: 215-A0211117A-M2300002A-M23A Registration Date/Time: 2015-10-2212:31:45 HERS Provider: CaICERTS
CA Building Energy Efficiency Standards Report Version: 2013-1.006 Report Generated: 2015-10-22 12:30:52
2013 Residential Compliance Schema Version: 0.555SDD
CERTIFICATE OF VERIFICATION CF3R-MCH-23-H
Space Conditioning System Airflow Rate (Page 2 of 4 )
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)
1050
03
Actual System Airflow Rate Measurement (cfm)
1070
04
Compliance Statement:
System airflow rate complies
E. Additional Requirements
Air filters that_meet_the applicable requirements of Standards Section 150.0(m)12 or 150.0(m)13 were properly installed in
01
the syster6-during system air flow. rate measurement identified on this Certificate of Verification.
The airflow ratemeasurement,apparatus used to perform ;the airflow rate measurementidentified on this Certificate of
02
Verification was' calibrated m accordance with the appaeatus manufacturer.'sspecif!cations and conforms to the '
o
instrumentation -specifications given in RA13 1.
A visual inspection shall confirm`that bypass 'ductsAhat deliverconditioned supply air -directly to the space conditioning
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 tested value.
Multi -speed compressor space cooling systems or variable speed compressor systems shall verify air flow (cfm/ton) and fan
08
efficacy (Watt/cfm) with system operating in cooling mode at the maximum compressor speed and the maximum 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 table have
been met unless otherwise noted in the Verification Status and the Corrections Notes in this table.
Registration Number: 215-A0211117A-M2300002A-M23A Registration Date/Time: 2015-10-22 12:31:45 HERS Provider: CaICERTS
CA Building Energy Efficiency Standards Report Version: 2013-1.006 Report Generated: 2015-10-22 12:30:52
2013 Residential Compliance Schema Version: 0.555SDD
CERTIFICATE OF VERIFICATION CF3R-MCH-23-H
Space Conditioning System Airflow Rate (Page 3 of 4 )
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 1 Complies: All specified verification protocol requirements on this document are met.
Registration Number: 215-A0211117A-M2300002A-M23A Registration Date/Time: 2015-10-2212:31:45 HERS Provider: CaICERTS
CA Building Energy Efficiency Standards Report Version: 2013-1.006 Report Generated: 2015-10-22 12:30:52
2013 Residential Compliance Schema Version: 0.555SDD
s},
1
A •'i
a�
1 � `'
{ S i t-
Registration Number: 215-A0211117A-M2300002A-M23A Registration Date/Time: 2015-10-2212:31:45 HERS Provider: CaICERTS
CA Building Energy Efficiency Standards Report Version: 2013-1.006 Report Generated: 2015-10-22 12:30:52
2013 Residential Compliance Schema Version: 0.555SDD
1
Registration Number: 215-A0211117A-M2300002A-M23A Registration Date/Time: 2015-10-2212:31:45 HERS Provider: CaICERTS
CA Building Energy Efficiency Standards Report Version: 2013-1.006 Report Generated: 2015-10-22 12:30:52
2013 Residential Compliance Schema Version: 0.555SDD
CERTIFICATE OF VERIFICATION CF3R-MCH-23-H
Space Conditioning System Airflow Rate (Page 4 of 4 )
Documentation Author's Declaration Statement
1. 1 certify that this Certificate of Verification documentation is accurate and complete.
Documentation Author Name:
Documentation Author Signature: ��77 ��TT
Cen
Ken Frazier
ccTrazier
Company:
Date Signed:
Golden State Energy Efficiency Services
2015-10-22 12:31:45
Address:
CEA/ HERS Certification Identification (if applicable):
1463 Circus Ct.
City/State/Zip:
Phone:
Turlock CA 95380
209-667-2164
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 bb 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 onthis Certificate' of Verification comply with_the,,applicable requirements in Reference Appendices RA2, RA3, and the requirements
specifi4or the Certificate of Compliance for the building approved by the enforcement agency.
4. The information reported on applicable sections of the Certificates) of Installat on:(CF2R) signetl a'nd,submitted;by the pers I n(s) responsible for the
construction or installation conforms to the requirements specrfied ori the Certificates) of Compliance (dill) approved by'the enforcement agency.
5. I will ensure that :a registered co" of this Certificate of Verrf cation `shall be osted,-or made available with fhe building ermit s issued for the
g P,,Y p g P ( )
building, and made available to the!;enforcement.agency for all applicable inspections I understand tfiat a,;registeredxopy of this Certificate of „
Verification is required to be mcluded with the documentation the builder provides to the building owner'at occupancy.
Builder Or Installer Information As Shown Or Th"ertificate�Of Installation '' a x`,, _
Company Name (Installing Subcontractor, General Contractor, or Builder/Owner):
CONVECTEK
Responsible Builder or Installer Name:
CSLB License:
Karl Hornung
953068
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:
Golden State Energy Efficiency Services
Responsible Rater Name:
Responsible Rater Signature: '7 2�-
Ken Frazier
cJCen c7razier
Responsible Rater Certification Number w/ this HERS Provider:
Date Signed:
CC2005910
2015-10-22 12:31:45
Digitally signed by CalCERTS. This digital signature is provided in order to secure the content of this registered document and in no way implies Registration Provider
responsibility for the accuracy of the information.
Registration Number: 215-A0211117A-M2300002A-M23A Registration Date/Time: 2015-10-22 12:31:45 HERS Provider: CaICERTS
CA Building Energy Efficiency Standards Report Version: 2013-1.006 Report Generated: 2015-10-22 12:30:52
2013 Residential Compliance Schema Version: 0.555SDD