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B-2016-1490CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2016-1490 10197 COLBY AVE CUPERTINO, CA 95014-2419 (316 28 042) ZHANG PENG AND HE OWNER'S NAME: ZHANG PENG AND HE NANNAN OWNER'S PHONE: 408-335-5215 LICENSED CONTRACTOR'S DECLARATION License Class Lic. # Contractor ZHANG PENG AND HE NANNAN 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: 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 10197 COLBY AVE CUPERTINO, CA 95014-2419 ISSUED: 03/21/2016 PHONE NO: BUILDING PERMIT INFO: BLDG X ELECT X PLUMB MECH X RESIDENTIAL _ COMMERCIAL JOB DESCRIPTION: BATHROOM REMODEL (119 S.F.), KITCHEN REMODEL (255 S.F.), OTHER REMODEL (626 S.F.), AND REMOVE SUNROOM. RELOCATE FURNACE TO ATTIC, TANKLESS WATER HEATER, UPGRADE ELECTRICAL PANEL (200 performance of the work for which this permit is issued. AMPS), 2. I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature Date 19 2 16 OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 1. I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) 2. I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). I 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 Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 2. 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. s. I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If, after making this certificate of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature 3yr_� Date 9 201 REV#1 -ADD SUBPANEL (100 AMP) IN LAUNDRY ROOM; ADD 12 RECESSED LIGHTS IN (E) BEDROOMS; & ADD 4 POWER OUTLETS IN 2 (E) BEDROOMS. Sq. Ft Floor Area: I Valuation: $50000.00 APN Number: Occupancy Type: 31628 042 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. n l Issued by: ALEX VALLELUNGA Date: 03/21/2016 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. Signature ofApplicant: Date: 5 1 2016 ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. Owner or authorized agent: Date: 5/1912016 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Address ARCHITECT'S DECLARATION I understand my plans shall be used as public records. CUPERTINO CONSTRUCT[ON PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 ' IV I (408) 777-3228 • FAX (408) 777-3333 - bllilding(C)CUDertlnO.orq Ae V n - ,yq rnNSTRIIC i ION n ADDITION ❑ ALTERATION / TI ❑ REVISION / DEFERRED ORI011,TAL PERMIT 701ECTADDRESS 6 17 o l �L 4ve 0INWERN.4ME � I PHONE 33 5 21 E_l,si4IL act` OW• v� STREET.SDDRESS /9 / Q "7 e'�I t "Ave I CITY, STATE, ZIP /�� �Y�i�a Y-oJ/_ I FAX CONTACT NAME �e1/J 2 pi V! PHONE /: I E-A^_A 1L -Z g'Cf I '-6 j^t @' I • L�Dy"•i STREET ADDRESS j 1 /'j ` � CITY, STATE, ZIP I FAX � �o v / 1 ev J`❑ �v LY� WAINIFR ❑ O-;MER-BliIIDER ElO-AWERAGENT ❑coN-jR?4cT0R ❑ CONTRACTORAGENT A.RCHITFCT ❑ ENGINEER ❑ DE' ELOPER ❑ TENANT CONTRACTOR NA -ME I LICENSE NUMBER LICENSE TYPE BUS. MC R COMPANYNAI,4E I E-biAJL FAX STREET ADDRESS CITY, STATE, ZIP PHONE a.RCHITECT(ENGD\tER NAME LICENSE NUAQBER BUS. LIC n CONIPAN'Y NAME E-?✓itIL I FAX STREET ADDRESS CITY, STATE, ZIP I PHONE DESCRIPTION OF i;'OPI: 12- ` V y'� A� 1 / u J _ _ _ // f N 1 , n e. _„ A % l `a J� �%GiA'l-�i� Y o U vy L. (� `VIJt EXISTING USE PROPOSED USE CONSTR. TYPE STORTE.S usE rYPE occ. sQ.r=r, v4iuATloN(s) EXISTG NEW FLOOR DEMO TOTAL AREA I AREA AREA NET AREA BATHROOM KITCHEN OTHER RE114,ODELAREA REMODEL AREA REMODEL AREA PORCH AREA DECK A AEA TOTAL DECKPORCH AREA G.-3 AGE ARFA: Lj DETACH ❑ ATTACH DWELL �D UNIT ❑YES COND STORY ❑ 1`ESL I BEING ADDED? El NO ADDITION". ❑?<O i PP.E-.-.P?LiCAT ION ❑ YES IF 1-S, PROVIDE CO?Y OF IS THE BLDG AN ❑ :'ES RECEI� ED B1 F ' TOTAL VALU�ATIO PLANTING APPL' ❑ NO PLAI\'�ING APPROV ^.L LETTER ETCHLER HO?,4E? ❑ NO .w �� 4., By my signature below, I certify to each of the following: I am the property owner or authorized went ,o act the property o\; ehzlf. I have read this application and the infomiation I have provided is correct. I have read the Description of Mork and verify it is accurate. I agree to comply with all applicable local ordinances and state la\\ s relztins to buildiD con tion. I authorize reps sentztives of Cupeftino to enter the above -identified propel ry for inspection purposes. Signature of Applicant/Agent: T SUTPLE\iNTALIl�i0RIv1ATIONREQL1I12LD 1\'e\;% SFD or AQuiti rinil d\; ellirgs: Ap 1 %for demolition emit for Y p p ❑ 01 ER Tr E COU\TrR x. ❑ rLtILDI\G ` — existing bulldmg(s). Demolition per-mit Is required prior to Issuance of bulldil:g PLA\ RE1 IE1i permit for new building. ;V$x}3 � � �lYRESS �t � f � �'r� ` �rti Cx'' SRi IaM *GC. Rr Al\L\G PL�'� RED IE`i � � zl I as.,s z K' ;_t' 9 s �'t.sr i j Commercial BldQS: Provide a completed -Hazardous Materials Disclosure >❑ ST \�4RD ❑� PLELIC\iCRha F sI§ — form if any ?-iazardous'•\�aterials are being i-,sed as part of this project. l tZ a n Lz� —rikFIREDEPT z 7 �" 1 prior to Cop} of Planninga .kpproval Letter or _\ eMing0 1luv:tn Planning S 3 ' ads a- t ci f t t z _ g 1J 1IAl0R A ❑ SL\ITzR] 15TRIC? S....., submittal of Building Petnnit application. E \r 1 s ❑c E\�-IRO\\iE\T.4I'HE.4LTH.-�� Bldg pp—?011.doc revised 06121111 CITY OF CUPERTINO BUILDING PERMIT BUIL.DINGADDRESS: 10197 COLBYAVE CUPERTINO, CA 95014-2419 (316 2& 042) OWNER'S NAME: ZHANG PENG AND HE NANNAN OWNER'S PHONE: 408-335-5215 LICENSED CONTRACTOR'S DECLARATION License Class Lic. # Contractor ZHANG PENGAND HE NANNAN 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: 1. 1 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. 2. I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature Date /23 1/16 hereby affirm that I am exempt from the Contractor's License Law for one of the CONTRACTOR: I PERMIT NO: B-2016-1490 ZHANG PENG AND HE 10197 COLBYAVE CUPERTINO, CA 95014-2419 ISSUED: 03/21/2016 PHONE NO: BUILDING PERMIT INFO: X BLDG X ELECT X PLUMB X MECH X RESIDENTLAL _ COMMERCIAL JOB DESCRIPTION: BATHROOM REMODEL (119 S.F.), KITCHEN REMODEL (255 S.F.), OTHER REMODEL (626 S.F.), AND REMOVE SUNROOM. RELOCATE FURNACE TO ATTIC, TANKLESS WATER HEATER, UPGRADE ELECTRICAL PANEL (200 AMPS). Sq. Ft Floor Area: I Valuation: $50000.00 APN Number: Occupancy Type: 316 28 042 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION, Issued by: Sean Hatch ving two reasons: All roofs shall be inspected prior to any roofing material being installed. If a roof is 1. I, as owner of the property, or my employees with wages as their sole installed without first 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) '2. 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: 3/21/16 I 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 Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 2. 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. ,\3. I certify that in the performance of the work for which this permit is issued, I T f shall not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If, after making this certificate of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. l ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as deemed by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino unfcipal Code, Chapter 9.12 and the Health & Safety Code, Sections 6025533, and 25534. Owner or authorized agent: Date: 3 121 16 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of works for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Address ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Date /3 21/16 Licensed CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 - build ingCcbcupertinfl.org ❑ ADDITION 15d ALTERATION 1 TT n R7_VTGT0_KT I nF.FF.RRRn ()RTr,MAT_PT2PWTbjuil V ""'"- I qu PR IEC ID S J +'ry'� r b y �] APN b`"-.✓ 4l�7�7` 0 RNAME PHONE 0 g88 —off_ Z E-MAIL STI I ET SS CIS Y, STATrCA E, ZIP 41� r f FAX C NTACT N MHONE � .j l.. b E-MAIL STREET CITY, STATE, ZIP ❑ owNER 0 OWNEr_BuiLDD-R 0 owNERAGENT © CONTRACTOR 0 CONTRACTOR AGENT ❑ ARCHITECT 1l ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE R 1TECTIE EER NAME LICENSE NUMBER BUS. LIC # � 1... O ` } COMPANY NA ' E FAX � STREET DDRESS CITY, STATE ZIP PHONE (� % DESCRIPTION OF WORK 1 � � ` j Ip'OL Y�AYY ,sir Z CS) Y'L1OCa, y i,/,t„fJ��Lw( !1 � , C A '+Au K vw rVrwL- - Movefka a i C4 �C tJN`Cot ir�G� S S + f r Gu`lti� y#TCWI a�'l�OC.I Ex TTNGUSE ��r�j1} PROPOSED CONSTR.TI i/�� �. VT}lZ #STORIES USE TYPE OCC. SQ.FT.. A tJ EXISTG AREA f J NEWFLOOR AREA �%1i��• DEMO AREA TOTAL NET AREA - - BATHROOM REMODELAREA //� `DECK KITCHEN REMODELAREOJ OTHER REMODEL AREA. PORCH AREA. AREA TOTAL DECKIPORCH ARE GARAGE AREA: DETACH © ATTACK I #Dll'ET GUNITS: TSASECONDUNIT ❑Y1S SECOND STORY YES - BEING ADDED? EINO ADDITION? []NO PRE -APPLICATION ❑YES IF YES. PROVIDE COPY OF ISTHEBLDGAN ❑YES �RECE['uEb BY - ' = -'..�-,. TOTAL VALUATION: NIN PLANCAPPL❑# NO PLANNING APPROVAL LETTER EICHLERHOMF? NO � "- - By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the property 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 relatuig tv building cmisruction. I author'ze representatives of Cupertino to enter the above -identified propeerttyfoorr i pection purposes. ` Signature of AppIieantlAgent: '�J Date: Y— vie l SUPPLEMENTAL mr.oRMATO UIRED 'I1,CHECKTPE _ - TBVGSLIP - i? OVER TFT$ CC!t1\TEI2; '": - - - suii.,n)"c'PIrAI: REVIE�i' New SFb or Multifamilydwellings: Apply rmolition permit for existing building(s). Demolition -permit is required prior to issuance of building permit for new building. )] RE35 �I A1�L\c I AAA tiEt°[E\, Commercial Bldgs: Provide a completed Hazardous Materials Disclosure _:k.:_:,,-::,:�:.v-s-,_:_-_;••_w�:<:: �:�;=...:....w__�_......__.--k5 =:: sTAi�DARD Wiz-_ems,==-::=�-,_..::��-:v:_ rIISLIc �n aRKS To in if any Hazardous Materials are being used as part of this project. F'Q L 4RGE Q FARE nPr Copy of Planning Approval Letter or Meeting with PIannina prior to MAiOR - -- SA\FTAR} SER£RDISTRICT submittal of Building Permit application. .. _ , ,_- :. - _ - ❑:E.li'IitOV14IEhTAL'Ii$ALTII .-= � P.S. BldgApp 2011,doc revised 06121111 t(5 �9'rJ CUPERTING OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT- BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building (5cupertino. 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._ -'b Ave APN.. # a OWNER NAME �-l� OWNER ADDRESS-, / y Co f k 4 Ve- DESCRIPTION OF WORK: 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.) 7-1..1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner - Builder" building permit that erroneously implies that the property owner is providing his or her own labor and material personally. I, as an Owner -Builder, may be held liable and subject to serious financial risk for any injuries sustained by an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers on my property. 3T2. 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. 3. I understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may pr tect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own, 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. t5. i understand if I employ or, otherwise engage any persons, other than California licensed Contractors, and the total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer" under state and federal law. 6. 1 understand if I am considered an "employer" under state and federal law, I must register with the state and federal government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject me to serious financial risk. 2 7. I 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. 7,W8. I understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for a y financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the workmanship or materials. OwnerBuilderForm 2010.docrevised04114110 I 19 1 understand i may obtain more information regarding my obligations as an"employer" from the Internal enue Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed contractors. 10. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I a 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 b all applicable laws and requirements that govern Owner -Builders as well as employers. 12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the in ormation 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 maybe in civil court. It- is also important for. you -to understand that if an unlicensed Contractor or employee of that individual or firm is injured while working on your property, you may be -'held liable for damages. If you obtain a permit as Owner -Builder and wish to hire Contractors, you will be responsible for verifying whether or not those Contractors are properly licensed and the status of their workers' compensation insurance coverage. CONSTRUCTION LENDING AGENCY (DIRECTIONS: Please complete the following construction lending agency information.) " 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 signature. Property Owner's Signature: Date: ----------------------------------------------------------------------------------------------------------------------------------------- (NOTE: The following Authorization Form is required to be completed by the property owner only when designating an agent of the property owner to apply for a construction permit for the Owner -Builder). AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize the following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an Owner -Builder Permit for my project. Scope of Construction Project (or Description of Work): Project Location or Address: Name of Authorized Agent: Address of Authorized Agent: Tel No 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 owners signature. Property Owner's Signature: Date: Ox,nerBuilderForm 2010.doc revised 04114110 L H C ARCHITECTURAL DESIGN & CONSTRUCTION —410 Architecture Design . Construction �✓ 13937 Lynde Avenue, Saratoga, CA 95070 Tel: (4088) 867-9331 Fax: (408) 867-9331 May 14, 2016 Project: Zhang Residence Renovation 10197 Colby Avenue Cupertino, CA 95014 Subject: Field observation As the architect of 'record, I had provide the structural field observation for the above mentioned project for the following items in the renovation area: 1- The hanger from beam to post @ powder room. Base upon the observation performed, it. is my professional judgment that the work was substantially in conformance with the approved building plans. Sincerely, 'ot- cL t Hau-Ching Liao Project Architect L h C ARCHITECTURAL DESIGN & CONSTRUCTION Architecture Design . ConstrUdion 13937 Lynde, A,vanue,. Saratoga, CA 95070 Tel: (408) 867-9331 Fax: (408) 867-9331 May 31, 2016 Project: Zhang Residence Renovation 10197 Colby Avenue Cupertino, CA 95014 Subject: Field observation As the architect of record, I had provide the structural field observation for the above mentioned project for the following items in the renovation area: 1- The beam on top of the double top plates with 4x4 post underneath instead of the ' beam to the post directly. Base upon the observation performed, it is my professional judgment that the work was substantially in conformance with the approved building plans. Sincerely, CL 149- Hau-Ching Liao Project Architect �5'C.1 ysr Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 Fax: 408-777-33333 } CONTRACTOR I SUBCONTRACTOR LIST JOB ADDRESS: five . _PERMIT OWNERS N r,AME: PHONE # GENERAL CONTRAC OR: BUSINESS LICENSE # ADDRESS. ° -.R ' CITY/ZIPCODE: -5 ' J a. - f . "U1 uiu>tijulpai cuue requires all pusinesses worxing m the city to have a City of Cupertino business license:" NO BUILDI G FINAL OR FINAL OCCUPANCY-IN-SPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL C NTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Signature Date Please check pplicable subcontractors and complete the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cemeni Finishing Electrical Excavation Fencing Flooring / Carpeting Linolet}m / Wood Glass / Glazing Pleating Insulation Landscaping - Lathing Masonry Painting / Wallpaper Paving Plasteriing Plumb' Roofing Septic Tank Sheet ?�etal Sheet Dock Tile 0 Owner /Contractor Signature WATER -CONSERVING PLUMBING FIXTURES l OWNER CERTIFICATE OF COMPLIANCE COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 1 CUPi~RT1NG 10300 TORRE AVENUE CUPERTINO, CA 95014-3255 � 1,3' � `� (F40 7�77-n3228 • FAX (408) 777-3333 • building&cupertino:org (Owner ame 2 I% into (1'ermi�l Ad ress 7" et7l Ave CctKerepo, CA Is-ol a Is your real property a registered historical site? Yes Civil Code Se�tions 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form. V No Go to Questio f 2. Does your real property Have fa 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? El Yes Civil Code Sections 1101.1 through 1101.8 do not apply. ❑ The licensed plumber's certification has been provided to the Building Division. Skip the rest of the form and sign bottom of form. No Go to Questio 3. Is water service permanent) disconnected for our building? Y Y g ❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form. No Go to Question 4. U Is your real property built and; available for use or occupancy on or before January 1, 1994? ❑ No My real prop e is built and available for use or occupancy after January 1 1994. Civil Code Section's 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form. ip 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.. Please check ONE of the following: 1A My property is a single-family residential real property. See Civil Code Section 1101.4. On and after January 1, 2614, 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 mult�amily residential real property. See Civil Code Section 1101.5. On and after January 1 12014, 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). ❑ My property is a coin ercial real property. See Civil Code Section 1101.5_ On and after January 112014, 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 throi tghout 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 1101.8, the current California Plumbing Code and California Green )lying Standards Code, and manufacturer's installation requirements, nd that the water-conservingplumbingfixtures comply with the requirements as indicated in the table on the following a s. (Owner or Owner Ag�emf igna u_re: LDa e: K Z% 16 Upon completing and signing this Certificate, please retain it to the Building Division in order to final your building permit. I SB4072015.doc revised 08126115 I i SMOKE I CARBON MONOXIDE ALARMS OWNER CERTIFICATE OF COMPLIANCE COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION G V PRTINt3 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building(aD_cupertino.org a �A ress t �I � ( t6 . (�wpeetct�W , CA _. _ - , PERMIT CANNOT BE FINALED AND COl% fl HAS BEEN iSIGNED AND RFT� URNEI PURPOSE This affidavit is a self - compliance with 2013 inspections are requir, GENERAL INFORM, Existing single-family Monoxide alarms. Wl $1000.00, CRC Section Monoxide Alarms be i -Zdt6-lq)v ATE ication for the installation of all required Smoke and Carbon Monoxide Alarms for Section R314, 2013 CBC Sections 420.6 and 907.2.11.2 where no interior access for', TION end multi -family dwellings shall be provided with Smoke Alarms and Carbon ?n the valuation of additions, alterations, or repairs to existing dwelling units exceeds Z314 and CBC Sections 907.2.11.5 and 420.6 require that Smoke Alarms and/or Carbon stalled in the following locations: AREA SMOKE ALARM CO ALARM Outside of each separate bedroom(s) sleeping area in the immediate vicinity of the I X X On every level of a dwelling unit including basements X X Within each sleeping room X i 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 Residen� aLCodes. The alarms have been tested and are operational, as of the date signed below. I have read and agree to comp!y with the terms and conditions of this statement Owner or owl--ge''nt'i) ame. ram+ �h► t� i na ure,......................... f , le�Z�lb (Con ractor Names Smoke and COform.doe revised 03118114 M N L: CERTIFICATE OF INSTALIATION CF R- C -20-H Duct Leakage Diagnosti Test (Page 1 of 3 ) Project Name: Peng Zhang Enforcement Agency: Cupertino Building Department Permit Number: B-2016-1490 Dwelling Address: 10197 Colby Ave. City: Zip Code: 95014 A. System Informatio 01 Space Conditioni g System Identification or Name System 1 02 Space Conditioning System Location or Area Served Whole house 03 Building Type fro rh CF-1R I Single family I 04 Verified Low Leakage Ducts in Conditioned Space No, credit is not taken (VLLDCS) Credit fr m CF1R? 05 Verified Low Leak ge Air Handling Unit (VLLAHU) Credit No, credit is not taken from CF1R? 06 Duct System Compliance Category Replacement B. Duct Leaka9009gla�fff���Iostic Test z fi �ti 01 Condenser Nomin 31 Cooling Capacity (ton) U.S. Energy RatersAssociation 02 Heating Capacity QkBtu/h) i 78.00 03 Conditioned FloorllArea served by this HVAC system (ft2) 1406 04 Duct Leakage Test Condition Test final 05 Duct Leakage Test Method Total leakage 06 Leakage Factor .06 J 07 Air Handling Unit Method Airflow (AHUAirflow) Determination Heating system method 08 Measured AHUAiflow 0 09 Calculated Target Ilowable Duct Leakage (cfm) 102 , 10 Actual duct leakage (cfm) rate from leakage test measurement 65 - 11 Compliance Statement System passes leakage test Registration Number: 316 1032422A-M2016881B-0000 Registration Date/Time: 2016-09-11 12:36:43 HERS Provider: USERA CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.007 Report Generated: 2016-09-11 12:36AS 2013 Residential Compliance Schema Version: 2013.1.007 CERTIFICATE OF INSTALII TION CF2R-MCH-20-H Duct Leakage Diagnostgc Test (Page 2 of 3 C. Additional Requirements for Compliance 01 System was tested in its normal operation condition. No temporary taping allowed. Outside air (OA) duct connections to the central forced air duct system shall not be sealed/taped off during duct leakage 02 testing. CA ducts used for Central Fan Integrated (CFI) Indoor Air Quality ventilation systems, or Central Fan Ventilation Cooling Systems, hatutilize dampers that open only when OA,is required and automatically close when CIA is not required, may configure the OA`damper to the closed position during duct leakage testing. 03 If a complete replacement, all supply and return register boots were sealed to the drywall. 04 Building cavities wereinot used as plenums or platform returns in lieu of ducts. 05 If cloth backed to pe was used it was covered with Mastic and draw bands. 06 All connection pgints between the air handler and the supply and return plenums are completely sealed. If the system cory plies 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 erification compliance. The responsible person signs#ure on�this cornphanc document ffirms that all apphcabI requirements intthis table have been meta Registration Number: CA Building Energy Efi 2013 Residential Com fN U.S. Energy Raters Association 032422A-M2016881B-0000 Registration Date/Time: 2016-09-11 12:36:43 HERS Provider USERA Standards Report Version: 2013 Rev 1.007 Report Generated: 2016-09-11 12:36:45 Schema Version: 2013.1.007 m - 3 CERTIFICATE OF INSTALI ATON , CF2R-MCH-20-H Duct Leakage Diagnostic Test (Page 3 of 3 ) Documentation Author's Declaration Statement II , 1. 1 certify that this C rtificate of Installation documentation is accurate and complete. Documentation Author Name: -_ Documentation Author Signature Com Liu Company: any: Signature Date: Santa Clara HERS 2016-09-11 Address: k CEA/ HERS Certification Identification (if applicable): 1181 Sundown Ln Il 410231431 City/State/Zip: Phone: San Jose CA 95127 408-883-3865 Responsible Person's Declaration statement I certify the following under p nalty of perjury, under the laws of the State of California: 1. The information p ovided on this Certificate of Installation is true and correct. 2. 1 am eligible uncle I Division 3 of the Business and Professions Code in the applicable classification to accept responsibility for the system design, construction, or in tallation of features, materials, components, or manufactured devices for the scope of work identified on this Certificate of Installation and afest to the declarations in this statement (responsible builder/installer), otherwise I am an authorized representative of the responsible build r/installer. 3. The constructed o installed features, materials, components or manufactured devices (the installation) identified on this Certificate of Installation conforms,to alU, ap 3licablecodes and regulations -and the installation conforms to the requirements:given on the plans andspecificationsapproved by the enforcement gency.I 4. I understand that HERS rater will deck the installat)on to verrfy compliance, and that if such checking identifies defectsy.l anrequired to take eorrective action t # t d t. t my expense. I umders and-tk�atEnergy Cbmmission and HERS Provide _epresentativesrwill also perfgrm quaTty assurance checking of installations, in( requirements of such ludmg those approved'as.part of a sample group_but-coot checked by a.HERS rater, andif those installations failito meet the qualIf sura�e chec , e;required corrective action and additional checking/testing of other' nstallations in that HERS 1, sample groinwill 5. I reviewed a copy a perfor` ed at xpense. f the Certficate of Compiia ee pproved by the enforcement agenncy that identifies the specific, equirements fQr fhe scope of construction or installation identified on this Certificate of Installa•�tion, and I have ensured that the requirements that apply to the construction or installation have been met. .S Ener Rater oclation 6. 1 will ensure that a registered copy of this Certificate of Installation shall be posted, or made available with the building permit(s) issued for the building, and mad 2 available to the enforcement agency for all applicable inspections. I understand that a registered copy of this Certificate of Installation is required to be included with the documentation the builder provides to the building owner at occupancy. Responsible Builder/Installer NI me: Responsible Builder/Installer Signature: Peng Zhang Company Name: (Installing Subcontractor or General Contractor or Position With Company (Title): e." Builder/Owner) Homeowner Peng Zhang pen hang (Sep 1, 2016) Homeowner Peng Zhang Address: CSLB License: 1328 Bonnet Ct N/A City/State/Zip: f Phone: Date Signed: San Jose CA 95132 4083355215 12016-09-11 Third Party Quality Control Pro ram (TPQCP) Status: Name ofTPQCP (if applicable): "phis digital signature is provided in order to secure the content of this registered document, and in no snag Implies Registration Provider responsibility for the accuracy of the 1hronnation." Registration Number: 316-A1032422A-M2016881B-0000 Registration Date/Time: 2016-09-11 12:36:43 HERS Provider: USERA CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.007 Report Generated: 2016-09-11 12:36:45 2013 Residential Compliancy Schema Version: 2013.1.007 d ; 1 r.� CERTIFICATE OF INSTALLATION CF2R-MCH-01-E Space Conditioning Systems, Ducts, and Fans (Page 1 of 8 ) roject Name: Peng Mang Enforcement Agency: Cupertino Building Department Permit Number: B-2016-1490 Dwelling Address: 10197 Colby Ave City: Zip Code: 95014 A. General Information 01 Dwelling Unit Name Peng Zhang 02 Climate Zone 4 03 Dwelling Unit Total Conditioned Floor 1406 04 Number of Space Conditioning 1 Area (ft2) Systems in this Dwelling Unit. 05 Certificate of Compliance Type Prescriptive alterations (CF1R-ALT) 06 Method used to Calculate HVAC Loads NotApplicableEquipmentChangeout 07 Calculated Dwelling Unit Sensible 0 08 Calculated Dwelling Unit Heating Load 0 Cooling Load(Btuh) (Btuh) 09 Dwelling Unit Number of Bedrooms 3 MCH-01b Pres ri tjve Alterations S ace-Conditio ,in S stems P�ucts end.�ans—. „ p � P �! g �Y a r -, ) r :';. ..mow m.-m ,.�r r �,,T. ....-.,.�'.. >"^ 6f % + p h B. Space Conditioning (SC) System Information,d x°� 01 :.:.�..02`` „*03 F U4 0 ' 06 07 08 09 10 ..r i SC System SC System CFA served S�� #t h Fln ti �g1l-,'j fore Installing installing Identification or Location or -Area -� --by this SC -- Y -- ducted containing system than 40 feet of entirely new entirely new SC - Alteration Type Name Served System (ftZ) —systerr►?— —component?— components? ducts? duct system? system? Entirely new or complete System 1 Whole house 1406 Yes Yes Yes Yes Yes Yes replacement space conditioning system Registration Number: 316-A1032422A-M0123586C-0000 Registration Date/Time: 2016-09-11 19:13:05 HERS Provider: USERA CA Building Energy Efficiency Standards - 2013 Residential Compliance Report Version: 2013 Rev 1.007 Report Generated: 2016-09-11 19:13:09 0 Schema Version: 2013.1.007 e CERTIFICATE OF INSTALLATION CF2R-MCH-01-E Space Conditioning. Systems, Ducts, and Fans (Page 2 of 8 ) C. $pace Conditioning (SC) System Alterations. Compliance Information 01 02 03 04 05 06 07 08 09 10 11 12 13 Central Fan Integrated Heating Cooling New or (CFI) System Altered Heating Minimum Altered Cooling Minimum Required Replaced New Ventilation Identification Heating Heating Efficiency Efficiency Cooling Cooling Efficiency Efficiency Thermostat Duct Duct System or Name System Type Component Type Value System Type Components Type Value Type Length R-Value Status All new System 1 Central gas heating AFUE .780 Central All new cooling SEER 14,000 Setback GT40Ft R6 Not a CFI furnace componen split AC system is components D. Installed Heating Equipment Information 01 02 03 04 05 06 07 System Identification or Heating Efficiency Heating Unit Heating Unit Heating Unit serial Rated Heating Capacity, Name Heating Efficiency Type Value Manufacturer Model Number number Output (BTUH) System 1 ' y I AFUE fE 97.000 Carrier 59 T%P.6A080E17 0816A45663 78000 . Notes: M a; 7,'If:1 d: ">;:, )^' d G ?! i n "Il 1 J „e-", -,- I °paw inform;\,�at• E. Installed Cooling�Equipme t ion " "" .�/p.`T✓k::r/$-#bzvx,Y2'.y, '✓d 'l4„vdaJu d, hum ANri6Y/J �5fWm;-v'!+a' ,-d-_ ._... _._ IM _ .�� 01 02143,9:r E . ;`4 l t i t k P r0_ t l It +LJd 07 OS Condenser or Package Unit Condenser or Condenser or Condenser or System Rated Cooling Condenser Rated System Identification Cooling Efficiency Cooling Efficiency Package Unit Package Unit Package Unit Capacity at Design Nominal Capacity or Name . Type Value Manufacturer Model Number Serial Number Conditions(BTUH) (ton) System 1 SEER 15.000 Carrier 24AAA0536A30 3316EO5483 36000 3.0 Registration Number: 316-A1032422A-M0123586C-0000 Registration Date/Time: 2016-09-11 19:13:05 HERS Provider: USERA CA Building Energy Efficiency Standards - 2013 Residential Compliance Report Version: 2013 Rev 1.007 Report Generated: 2016-09-11 19:13:09 Schema Version: 2013.1.007 CERTIFICATE OF INSTALLATION CF2R-MCH-01-E Space Conditioning Systems, Ducts, and. Fans (Page 3 of 8 ) E. Installed Cooling Equipment information 01 02 03 04 05 06 07 08 Condenser or Package Unit System Identification, or Name Cooling Efficiency Type Cooling Efficiency Value Condenser or Package Unit Manufacturer Condenser or Package Unit Model Number Condenser or Package Unit Serial Number System Rated Cooling Capacity at Design Conditions (BTUH) Condenser Rated Nominal Capacity (ton) Notes: F. Extension of Existing Duct System, Greater Than 40 Feet This section does not apply to this project. G. Installed Duct System information _ 01 02 03 04 05 06 07 08 09 Method of Can RA3.3 compliance with Airflow SC System SCSytem ( j' duct and filter Number of Air Protocols be Identification Or Locationor A�Fea Supply Duct ` h Supply Duct; xl2eturn,Duc Ret rn Duct grille sizing Req's Filter Devices on used to test Name ! erne Serveed Location b R=Value Locations R Ualue°' in 150.0(m)13 System ? this system. q Ilk HERS verified fan System 1 Whole house Unconditio : e y R_�co Eat d�ioned efficacy (W/cfm) 1 Yes attic �alH� t r �fiti"►'ii and airflow rate _- (cfm ton) Notes: Registration Number: 316-A1032422A-M0123586C-0000 Registration Date/Time: 2016-09-11 19:13:05 HERS Provider: USERA CA Building Energy Efficiency Standards - 2013 Residential Compliance Report Version: 2013 Rev 1.007 Report Generated: 2016-09-11 19:13:09 Schema Version: 2013.1.007 CERTIFICATE OF INSTALLATIONCF2R-MCH-01-E Space Conditioning Systems, Ducts, and Fans (Page 4 of 8 ) H. Installed Air Filter Device Information 01 02 03 04 05 06 07 SC System Identification or Name SC System Location or Area Served Air Filter Identification or Name Air Filter Device Type Air Filter Device Location Determined Design Airflow Rate for Air Filter Device (cfm) Determined Design Allowable Pressure Drop for Air Filter Device (inch W.C.) System 1 Whole house Filter Filter Grille FilterGrille 800 .010 Notes: I. Air Filter Device Requirements 01 The system shall be designed to ensure that all recirculated air and all outdoor air supplied to the occupiable space is filtered before passing through the system's thermal conditioning components. The system shall be designed to accommodate the clean -filter pressure drop imposed by the system air filter device(s). The design airflow rate and maximum allowable clean -filter pressure drop at the design airflow rate applicable to each air filter device shall be determined, and all system air filter device locations shall be 02 labeled to disclose the applicable design airflow rate and the ma 'mum allowable clean -filter pressure drop. The labels shall be permanently affixed to the air filter device, r{ ad'ily legible, and visible to a personfreplac,ngtkjea filter media nd the air filter devicehall be provided with air filter media that conforms to these determi ed or labeled mimmIlowable.elean filter ropivalues as rat —using AHRI�St nd�` rd 680. pressure 03 All system ai' filter devices shall be located and instal edrin s ch a maij ne" igtio allo access �andrregularservice by the system owner. 04 s*: i,cd�;4."m^xx'JW; '.+�" The system shall be provided truiti air filter rrrediah e�sig=n�atedeffiency eq�uor greater thanMERV 6 when tested in accordance with ASHRAE Standard . 52.2, or a article size efficient satin a ual to o p y g q g p e 3.0 to10 micron range when tested in accordance with AHRI Standard 680. tCrn7u Treater r^ i�an � 9FA-- A jmae%r%i!n n 05 The system shall be provided with air filter media that has been labeled by the manufacturer to disclose the efficiency and pressure drop ratings that conform to the required efficiency and pressure drop requirements for the air filter device. The responsible persons signature on this compliance document affirms that all applicable requirements in this table have been met. Registration Number: 316-A1032422A-M0123586C-0000 Registration Date/Time: 2016-09-11 19:13:05 HERS Provider: USERA CA Building Energy Efficiency Standards - 2013 Residential Compliance Report Version: 2013 Rev 1.007 Report Generated: 2016-09-11 19:13:09 Schema Version: 2013.1.007 CERTIFICATE OF INSTALLATION CF2R-MCH-01-E Space Conditioning Systems, Ducts, and Fans (Page 5 of 8 J. HERS Verification Requirements 01 02 03 04 05 06 07 08 09 10 MCH2O MCH21 MCH22 MCH23 MCH25 MCH28 Exemption from Minimum Exemption R-Value for AHLI System SC System From Duct Duct Ducts In Ducts Located AHU Fan Airflow Identification or, Location or Area Leakage Leakage Conditioned In Cond Space Efficacy Rate Refrigerant Return Duct Design Name Served Requirements Test Space Verification (W/cfm) (cfm/ton) Charge Table 150.0-C or D System 1 Whole house No Yes No No Yes Yes No No exemptions Exemption Notes: �, ..✓zc ,..5 .n:�, �, „w,.:..,:,� ,�t w i �. .x';H,ar,,;,, U.S. Energy,Raters Association Registration Number: 316-A1032422A-M0123586C-0000 Registration Date/Time: 2016-09-11 19:13:05 HERS Provider: USERA CA Building Energy Efficiency Standards - 2013 Residential Compliance Report Version: 2013 Rev 1.007 Report Generated`. 2016-09-11 19:13:09 Schema Version: 2013.1.007 CERTIFICATE OF INSTALLATION CF2R-MCH-01-E Space Conditioning Systems, Ducts, and Fans (Page 6 of 8 ) K. Space Conditioning Systems, Ducts and Fans Mandatory Requirements and Additional Measures Note: Additional mandatory requirements from Section 150.0 that are not listed here may be applicable to some systems. These requirements may be applicable to only newly installed equipment or portions of the system that are altered. Existing equipment may be exempt from these requirements. Heating Equipment Equipment Efficiency: All heating equipment must meet the minimum efficiency requirements of Section 110.1 and Section 110.2(a) and the Appliance Efficiency 01 Regulations. Controls: All unitary heating systems, including heat pumps, must be controlled by a setback thermostat. These thermostats must be capable of allowing the occupant 02 to program the temperature set points for at least four different periods in 24 hours. See Sections 150.0(i), 110.2(b).. Sizing: Heating load calculations must be done on portions of the building served by new heating systems to prevent inadvertent undersizing or oversizing. See sections 03 150.0(h)1 and 2). Furnace Temperature Rise: Central forced -air heating furnace installations must be configured to operate at or below the furnace manufacturer's maximum 04 inlet -to -outlet temperature rise specification. See Section 150.0(h)4. 05 Standby Losses and Pilot Lights: Fan -type central furnaces may not have a continuously burning pilot Fight. Section 110.5 and Section 110.2(d).. Cooling Equipment Equipment Efficiency: AI;I cooling equipment.must L eet t ee m nimum iffsic ency quire Tents of Sedation 110.1 and Section 110.2(a) and the Appliance Efficiency 06 Regulations. k"+...'. k. r .'+ 1. 07 i gerar�e insulatdion in split system Refri eran Line Insulation: All refs g nt Ii air conditioners and heatpunpsmust meet the R-value and protection requirements of Section 150.0(j)2 nd 3, and"Section 15A.,z0(m)9 t. ' 08 Condensing Unit Location: Condensing units shall n, b . la �e ' 'i��yl(i f, el �����eat� f+a dgy`erNIpc1 t �:e _ Section 150.0(h)3A. A ip� i 1 )b2i. i�i 'IYA �^.'4' 9.&' l Abi Sizing: Cooling load calculations must be done on portions of the building served by new cooling systems to prevent inadvertent undersizing or oversizing. See Section —QO _ 150.0(h)1 and 2. Air Distribution System Ducts, Plenums and Fans Insulation: In all cases, unless ducts are enclosed entirely in directly conditioned space, the minimum duct insulation value is R-6. Note that higher values may be 10 required by the prescriptive or performance requirements. See Section 150.0(m)1. Registration Number: 316-A1032422A-M0123586C-0000 Registration Date/Time: 2016-09-11 19:13:05 HERS Provider: USERA CA Building Energy Efficiency Standards - 2013 Residential Compliance Report Version: 2013 Rev 1.007 Report Generated: 2016-09-11 19:13:09 Schema Version: 2013.1.007 " n e CERTIFICATE OF INSTALLATION CF2R-MCH-01-E Space Conditioning Systems, Ducts, and. Fans (Page 7 of 8 ) K. Space Conditioning Systems, Ducts and Fans Mandatory Requirements and Additional Measures Note: Additional mandatory requirements from Section 150.0 that are not listed here may be applicable to some systems. These requirements may be applicable to only newly installed equipment or -portions of the system that are altered. Existing equipment may be exempt from these requirements. Connections and Closures: All installed air -distribution system ducts and plenums must be, sealed and insulated to meet the requirements of CIVIC Sections 601.0, 11 , 602.0, 603.0, 604.0, 605.0 and ANSI/SMAC NA-006-2006: Supply -air and return -air ducts and plenums must be insulated to a minimum installed level of R-6.0 or enclosed entirely indirectly conditioned space as confirmedthrough field verification and diagnostic testing in accordance with the requirements of Reference Residential Appendix RA3.1.4.3.8. Heat Pump Thermostat 12 A thermostat shall be installed that meets the requirements of Section 110.2(b) and Section 110.2(c). 13 The thermostat shall be installed in accordance with the manufacturers published installation specifications 14 First stage of heating shall be assigned to heat pump heating. 15 Second stage back up heating shall be set to come on only when the indoor set temperature cannot be met. The responsible, person signature on this compliance document affirms that all applicable requirements in this table have been met. U.S.Energy Raters Association Registration Number: 316-A1032422A-M0123586C-0000 CA Building Energy Efficiency Standards - 2013 Residential Compliance Registration Date/Time: 2016-09-11 19:13:05 Report Version: 2013 Rev 1.007 Schema Version: 2013.1.007 HERS Provider: USERA Report Generated: 2016-09-11 19:13:09 CERTIFICATE OF INSTALLATION CF2R-MCH-01-E Space Conditioning Systems, Ducts, and Fans (Page 8 of 8 ) Documentation Author's Declaration Statement 1. 1 certify that this Certificate of Installation documentation is accurate and complete. Documentation Author Name: Documentation Author Signature. l Minxuan Liu I ,I Company: Signature Date: Santa Clara HERS 2016-09-11 Address: CEA/ HERS Certification Identification (if applicable): 1181 Sundown Ln 1410231431 City/State/Zip: Phone: San Jose CA 95127 1408-883-3865 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 Installation is true and correct. 2. 1 am eligible under Division 3 of the Business and Professions Code in the applicable classification to accept responsibility for the system design, construction, or installation of features, materials, components, or manufactured devices for the scope of work identified on this Certificate of Installation, and attest to the declarations in this statement (responsible builder/installer), otherwise -I am an authorized representative of the responsible builder/installer. 3. The constructed or installed features, materials, components or manufactured devices (the installation) identified on this Certificate of Installation conforms to all applicable codes and regulations, and the installation conforms to the requirements given on the plans and specifications approved by the enforcement agency. 4. I reviewe,d,a copy of the Certificate of Compliance; a pproveoibyathedenforcemen agency„tbat identifies�the specific requirements for the scope of construction or installation identified on this Certificate of Installat n, and I have en used that the requirements'hatpply #q tie cAnstrutionor;installatighave been met.Q 5. 1 will ens re that a registered copy ofth s Certificate,,of Installation shall be posted o made availabl'-Awi the buildmg^p�eftmit(s) issued for the building, and made available to the enforcement agency for all applicably inspections. I u derstand,that 51dkistered copy of fhis; Certificate of Instal a#� n s�required�to'be included wgth the;documentation the builder provides to the building owner at occupancy. Responsible Builder/Installer Name ( Responsible Builder/Installer Signature; Peng Zhang Company Name: (Installing Subcontracto'r"or General prof Build�e'rr;%0.W�ne�r) Po�h. ompany (Titlef' , ey Qh Homeowner Peng Zhang n - , �' � v Peng ang (Sep 11, 16) Address ., : Energy irt('II ZUB- iceageas d `,41 1328 Bonnet Ct.. _ _ _, N/A City/State/Zip: Phone: Date Signed: San Jose CA 95132 4083355215 2016-09-11 T1 JL—alThis digital sign tur6 is provided in order to secure MrWR U f? the content of this registered document, and in no !gay implies Registration Provider responsibility for the accuracy of the information." Registration Number: 316-A1032422A-M0123586C-0000 Registration Date/Time: 2016-09-11 19:13:05 HERS Provider: USERA CA Building Energy Efficiency Standards - 2013 Residential Compliance Report Version: 2013 Rev 1.007 Report Generated: 2016-09-11 19:13:09 Schema Version: 2013.1.007 m it } r!,, CERTIFICATE OF INSTALLATION CF2R-MCH-22-H Space Conditioning System Fan Efficacy (Page 1 of 3 ) Project Name: Peng Zhang Enforcement Agency: Cupertino Building Department Permit "Number: B-2016-1490 Dwelling Address: 10197 Colby Ave City: Zip Code: 95014 A. Ducted Cooling Sy tem,, Information 01 System Identificat�on or Name System 1 02 System Location or Area Served Whole house 03 System Installatiok Type Replacement 04 Nominal Cooling Capacity (tons) of Condenser 3.0 05 Condenser Speed Ifype Single Speed 06 Cooling System Zollinal Control Type Not Zonal 07 Central Fan Integrated (CFI) Ventilation System Status Not a CFI system 08 System Bypass Duct StatusIVo i Bypass "Duct , 09 i Date of Sy €tert Airflow e r Rate# Measurement i 1 2016 09-09'a -mT` 10 Airflow Ralie"Pliotocol utilized I y RA3.3 procedures%for airflow rate measurement r "`? i B. Fan Watt MeasurementfApparatus and ProcedurLfm9r.rrF&r argy Rater Association 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 f MCH-22a Forced Air system Fan Efficacy Measurement - Newly Installed Non -Zoned Systems or Zoned Multi -Speed Compressor it C. Forced Air System The procedures for Sy Fan Efficacy Measurement I Ltem Fan Watt Verification are specified in Reference Residential Appendix RA3.3 01 Actual Tested Watts I 565 02 Actual Tested Airflow from MCH-23 (cfm) 1070 03 Required Fan Efficacy (watts/cfm) .58 04 Actual Fan Efficacy (watts/cfm) .53 05 Compliance Statement; System fan efficacy complies Registration Number: 316-P 1032422A-M22003092A-0000 CA Building Energy Efficiency Standards 2013 Residential Compliance 'Registration Date/Time: 2016-09-11 12:38:33 HERS Provider: USERA Report Version: 2013 Rev 1.007 Report Generated: 2016-09-11 12:38:35 Schema Version:0.52SDD I W CERTIFICATE OF INSTALL4TION - CF2R-MCH-22-H Space Conditioning Sys i em Fan Efficacy (Page 2 of 3 ) D. Additional Requir rnents 01 All registers were fully open during the diagnostic test. 02 System fan was sit 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 fin watt draw shall be simultaneous measurements when used to calculate the Fan Efficacy tested value. 05 Multi -speed compressor efficacy (Watt/cfm) handler fan speed. space cooling systems or variable speed compressor systems shall verify air flow (cfm/ton) and fan with system operating in cooling mode at the maximum compressor speed and the maximum air 06 Zoned cooling air (Watt/cfm) criteriI distribution systems with single speed compressors shall meet both the airflow (cfm/ton) and fan efficacy in every zonal control mode. The responsible persons been met. signature on this compliance document affirms that all applicable requirements in this table have Registration Number: 31E CA Building Energyffficie 2013 Residential Complia j Z trr .:a?F I s �; W2A-M22003092A-0000 Registration Date/Time: 2016-09-11 12:38:33 HERS+Provider: USERA indards Report Version: 2013 Rev 1.007 Report Generated: 2016-09-11 12:38i3S Schema Version: 0.52SDD CERTIFICATE OF INSTAILATION CF2R-MCH-22-H I Space Conditioning System'Fan Efficacy (Page 3 of 3 ) I Documentation Au+r's Declaration Statement 1. I certify that this Certificate of Installation documentation is accurate and complete. Documentation Author Name:! Minxuan Documentation Author Signature: Liu Company: Signature Date: Santa Clara HERS _ 2016-09-11 Address: j CEA/ HERS Certification Identification (if applicable): 1181 Sundown Ln II 410231431 City/State/Zip: Phone: San Jose CA 95127 1408-883-3865 Responsible Person'slDeclaration 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 Installation is true and correct. 2. 1 am eligible under Division 3 of the Business and Professions Code in the applicable classification to accept responsibility for the system design, construction, or installation Installation and attest of features, materials, components, or manufactured devices for the scope of work identified on this Certificate of to the declarations in this statement (responsible builder/installer), otherwise I am an authorized representative of the responsible builder/installer. 3. The constructed or installed features, materials, components or manufactured devices (the installation) identified on this Certificate of Installation conform,,s,to_alapplicable,codes theenfor*cement(gency. and regulations,:and the installation,conformsjo the requiremerttsgiven on the plans.andspecifications approved by 4. I understand that�a 1 HERS rater>will check the installatj n to verify compliance, and that if `such check ng identifies defects J am required to take , r. corrective action of installations, including g ; � t my expensle. I unc(erstandtthat Energy CiOrtmission and(HERS Proyider`�representativesiWill alsoperform qua�ty assurance checking t so approved, part of a sample group�but-no checked by a HERS rater, and'if those installations faill�to meet the requirerrentsof sich sample group wiI e quality assura ce checking t e required corrective action and additional checking/testing of otherinst`allations in that HERS be p fntamed at�y?expense 5. 1 reviewed acopy • f the Lett icate ofgCoQNpi�iance approved by the enforcementt agency at identifies thespecificrequirements for the scope of construction or installation installation have been identified on this Certificate of installation, and I have ensured that the requirements that apply to the construction or met. U.S... EnergyRater Association 6. 1 will ensure that a registered copy of this Certificate of Installation shall be posted, or made available with the building permit(s) issued for the building, and mace available to the enforcement agency for all applicable inspections. I understand that a registered copy of this Certificate of Installation is req fired to be included with the documentation the builder provides to the building owner at occupancy. Responsible Builder/Installer (Jame: Responsible Builder/installer Signatures Peng Zhang Company Name: (Installing Subcontractor or General Contractor or Position With Company (Title): gy Builder/Owner) I Homeowner Peng Zhang Peng Pang (Sep 11 -016) Homeowner Peng Zhang' Address: CSLB License: 1328 Bonnet Ct N/A City/State/Zip: Phone: Date Signed: San Jose CA 95132 + 4083355215 2016-09-11 Third Party Quality Control program ;(TPQCP) Status: Name of TPQCP (if applicable): JK T AM 'This digital signature is provided in order to secure RAw -AW the content of this registered document, and in no way implies Registrafton Provider responsibitity. for . r atar A atf tt the accuracy of the. information.' RegistrationNumber: 3164,1032422A-M22003092A-0000 Registration Date/Time: 2016-09-11 12:38:33 HERS Provider: USERA CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.007 Report Generated: 2016-09-11 12:38:35 2013 Residential Compliance Schema Version: 0.52SDD CERTIFICATE OF INSTALLATION `CF2R-MCH-23-H Space Conditioning System Airflow Rate (Page 1 of 3 ) Project Name: Peng Zhang Enforcement Agency: Cupertino Building Department Permit Number: B-2016-1490 Dwelling Address: I 10197 Colby Ave City: Zip Code: 95014 A. Ducted Cooling System; Information ' 01 System Identificatjon or Name System 1 02 System Location or Area Served Whole house 03 System Installation Type Replacement 04 Nominal Cooling Capacity (tons) of Condenser 3.0 05 Condenser SpeedlType IIIIII Single Speed 06 Cooling System Zonal Control Type I Not Zonal 07 Central Fan Integrated (CFI) Ventilation System Status Not a CH system 08 System BypassiDuct Status No Bypass Duct ,_ 09 Date of S s em Airflow y late R Measuremen`nrt 201fi-09-09¢ a' 10 Airflow Rate Protocol utilized I RA3 3 plroceduressfor airflow rate measur=ement B._Hole for the placement: of'�a Static Pressure Prob es-6P),EMEr Yn stale i i?ri t P'Iobe (PSPP) in the supply plenum Procedures for installi g HSPP or PSPP are specified in RA3.3.1.1. 01 Method used to demonstrate compliance with the HSPP installed and labeled consistent with Figure RA3.3-1 HSPP/PSPP requirement I C. Airflow Rate Measurement Apparatus and Procedure Information Instrument Specificatil ns 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. RA3.3.3.1.4 02 Manufacturer of Airflow lYleasurement i Apparatus Alnor 03 Model number of Airflow I Measurement Apparatus 634-513-044 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: 316-A1032422A-i CA Building Energy Efficiency Standards 2013 Residential Compliance Registration Date/Time: 2016-09-11 T12:37:3 HERS Provider: USERA Report Version: 2013 Rev 1.007 Report Generated: 2016-09-11 12:37:41 Schema Version:. 0.555SDD CERTIFICATE OF INSTALLATION CF2R-MCH-23-H Space Conditioning System Airflow Rate (Page 2 of 3 I MCH-23a Forced Air System Airflow Rate Measurement - Newly Installed Non -Zoned Systems or Zoned Multi -Speed Compressor i e D. forced Air System The procedures for System Airflow Rate Measurement 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 Air low Rate Measurement (cfm) 1070 rO4 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 system during system air flow rate measurement identified on this Certificate of Installation. The airflo + rate measurement apparatus usedto perform the airfea'low rate r V'renien identified on this Certificate of 02 Installatio was calibrated in acc�Ordarrce with the apparatus mas nufact rer'.specifications and cbriforms to the instrumentppation specificatiog':ns give n---in3 3 1} 6 - r-4� A visual inspection shall confirm t`at bypass -ducts that delivero itionedlsupply air directly to the spac&c nditioning 03 system return duct of Compliance indicates airflow are not used on newly constructed zonally controlled systems unless the Performance Certificate an allowance for use of a b a i i f ypi s s act d o r,ice j 4rlormance Certificate of Compliance, the airflow rate shall conform to the specifications listed on the Certificate of Compliance. }fullybpen 04 All registers were during the diagnostic test. 05 System fan was s It at maximum speed during the diagnostic test. 06 If fresh air duct is (part I of the HVAC system it was not closed during the diagnostic test. 07 Airflow rate and fin 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/cf j) with system operating in cooling mode at the maximum compressor speed and the maximum air handler fan speed. The responsible persons signature on this compliance document affirms that all applicable requirements in this table have been met. Registration Number: CA Building Energy Eff 2013 Residential Coml Registration Date/Time: 2016-09-11 T12:37:3 HERS Provider: USERA Report Version: 2013 Rev 1.007 Report Generated: 2016-09-11 12:37:41 Schema Version: 0.555SDD CERTIFICATE OF CF2R-MCH=23-H Space Conditioning Sys itern Airflow Rate (Page 3 of 3 ) Documentation Author's Declaration Statement 1. I certify that this Certificate of Installation documentation is accurate and complete. Documentation Author Name: Documentation Author Signature: I ' Minxuan Liu S Company: Signature Date. �V Santa Clara HERS 2016-09-11 Address: CEA/ HERS Certification Identification (if applicable): 1181 Sundown Ln 410231431 City/State/Zip: Phone: San Jose CA 95127 408-883-3865 Responsible Person'siDeclaration 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 Installation is true and correct. 2. 1 am eligible under Division 3 of the Business and Professions Code in the applicable classification to accept responsibility for the system design, construction, or i i stallation of features, materials, components, or manufactured devices for the scope of work identified on this Certificate of Installation and attest to the declarations in this statement (responsible builder/installer), otherwise I am an authorized representative of the responsible builder/installer. 3. The constructed c r installed features, materials, components or manufactured devices (the installation) identified on this Certificate of Installation conforms,to,gq aplplicablecodejs and regulations, and the in, stallation.conforms-to the_requirements,given on the plans,andspecifications approved by the enfo cement agency. 1 _ ik a 4. I understand that a HERS r ter will ec�C the installation to verify compliance, d that if such checkmg.id ntifies defects;.) a required to take corrective action t my expense. I understand°that,Energy Commission-and�HERS Provider representatroeswi11 also perform quality assurance checking of installations, including t o'se approv as:pa of a sample group.[ ut not checked by a HERS rater, an 'if those installations fail5to meet the require ?nts of sLch oup quality assurance checking t e required corrective action and ddifional checking/testing of otherinstallati�ns in that HERS sample g ill be perforymed at mexpenser� 5. 1 reviewed a cgpy of the C�ert icate ofrCo plia ce approved by the enforcementf agency tl,3at identifies these cif c equirement�{or the scope of construction or in installation have teen tallation identified on this Certificate of Installation, and I have ensured that the requirements that apply to the construction or met. U.S., Energy Raters Association 6. 1 will ensure that a registered copy of this Certificate of Installation shall be posted, or made available with the building permit(s) issued for the building, and made available to the enforcement agency for all applicable inspections. I understand that a registered copy ofthis Certificate of Installation is req ired to be included with the documentation the builder provides to the building owner at occupancy. Responsible Builder/Installer Nlame: Responsible Builder/Installer Signature: Peng Zhang Company Name: (Installing Subcontractor or General Contractor or Position With Company (Title)': e„ Builder/Owner) Homeowner Peng Zhang Peng Ofiang (Sep 11 016) Homeowner Peng Zhang Address: CSLB License: 1328 Bonnet Ct N/A City/State/Zip: Phone: Date Signed: San Jose CA 95132 4083355215 2016-09-11 Third Party Quality Control Program (TPQCP) Status: Name of TPQCP (if applicable): 'This digital signature ispmvidedin order to secure the content of this registered document, and in no way imp ties Registralion Provider responsibility for the accuracy of the information.' Registration Number: 316- 1032422A-M2313351A-0000 Registration Date/Time: 2016-09-11 T12:37:3 HERS Provider: USERA CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.007 Report Generated:2016-09-11 12:37:41 2013 Residential CompliancIe Schema Version: 0.555SDD