B-2016-1945 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-1945
10340 S BLANEY AVE CUPERTINO,CA 95014-3121(369 11 055) AIR&PLUMBING
SYSTEMS INC
LOS GATOS,CA 95032
OWNER'S NAME: KOTITE NICOLAS AND ROULA DATE ISSUED:05/13/2016
OWNER'S PHONE:408-507-1466 PHONE NO:(408)733-2000
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C-36:C-20 Lic.#901246
Contractor AIR&PLUMBING SYSTEMS INC Date 07/31/2017 X BLDG —ELECT —PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing X MECH X RESIDENTIAL COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
(R)FURNACE&AIR DUCTS-SAME LOCATION;ADD A/C-SIDE OF
I hereby affirm under penalty of perjury one of the following two declarations: GARAGE
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.
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. Sq.Ft Floor Area: Valuation:$11500.00
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 APN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 369 11 055
representatives of this city to enter upon the above mentioned property for
inspection purposes. (We)agree to save indemnify and keep harmless the
City of Cupertino against liabilities,judgments,costs,and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply with all non-point
source regulations per the Cue ' I Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature_ Date 5/13/2016 Issued by:Abby Ayende
Date:05/13/2016
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS:
following two reasons: I All roofs shall be inspected prior to any roofing material being installed.If a roof is
1. 1,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(See.7044,Business&Professions Code). Date:5/13/2016
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
t. I have and will maintain a Certificate of Consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
2. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534. I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
3. I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(a)should I store or handle hazardous
shall not employ any person in any manner so as to become subject to the material. Additionally,should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 25505,255
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revolted. Owner or authorized agent:
APPLICANT CERTIFICATION Date:5/13/2016
1 certify that I have read this application and state that the above information is CON TRUCfION LENDING AGENCY
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending agency for the performance
relating to building construction,and hereby authorize representatives of this city of work's for which this permit is issued(Sec.3097,Civ C.)
to enter upon the above mentioned property for inspection purposes. (We)agree Lender's Name
to save indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs,and expenses which may accrue against said City in Lender's Address
consequence of the granting of this permit. Additionally,the applicant understands
and will comply with all non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Licensed
Signature Date 5/13/2016 Professional
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 miCUPERTiNQ (408)777-3228•FAX(408)777-3333•buildingCcDcupertino.om sc
❑PLUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS `O2 APN- 7
OWNER NAME /' PHONE[4yll-o7—
/ { E MAIL (X,?a\ C 20lot
STREETADDRESS /��7 / CITY, STATE,ZIP b� /(cC FAX
®®®
CONTACT NAME Q PHONE t.6PL 7-> a q/��� O2 E-MAIL/17 ���Q0( // /L /FCO-
STREET ADDRESS `✓k/�� /f OYL CITY,STATE,ZIP r/I� �O ��( FAX QO /�J'27�
❑OWNER ❑ OWNER-BUILDER ❑ OWNERAGENT ❑ CONTRACTOR ❑CONTRACTOR(AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME /2 a LICENSE NUMBER ,?1 / LICENSE TYPE ZO BUS.LIC#
COMPANY NAME / ( i1 \ E-MAIL
{' L FAX
//7 1�•��iv� s v s /7a��� G��i� �to� l�/MLI'g C'0�
1-1
STREET ADDRESSn �� �d n A,� CITY,STATE,ZIP �q a PHONE 6P T5
ARCHITECT/ENGINEER NAME 4 V ICENSE NUMBER "l BUS.LIC#CL
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WH.DLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑ NO
DESCRIPTION OF WORKdell
G(Dl -e a..R! Q
TOTAL VALUATION: RECEIVED$Y.:
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property o per's b half. I have read this
application and the infonnation I have provided is correct. I have rea a e�tlon o o k and verify it is accurate. I agree to compI with all applicable local
ordinances and state laws relating to building construction. o' eprese pertino>Q enter the above-identi d prope for inspection purposes.
Signature of Applicant/Agent: Date: 4Ceb
SUPPLE AL INFORMATION REQUIRED oficE usE oNz
%�.,� O OVER THE COUNTER
Ti
EXPRESS
STANDARD
��"'� ❑ LARGE �
Mr1JOR
MEPM1scApp_2011.doc revised 06/21/11
STATE OF CALIFORNIA
ALTERATIONS - HVAC
CEC-CF1R-ALT-03-E Revised 06/14 CALIFORNIA ENERGY COMMISSION
CERTIFICATE OF COMPLIANCE CF1R-ALT-03-E
Alterations-HVAC CZ 1,3 to 7 and 16(formerly CF-1R-ALT-HVAC) (Page 1 of 1)
Site Address: MNA
orcement Agency: Date Prep red: Permit#:
Equipment Type Equipment Efficiency New: u ing,P nums,Lineset Conditioned Thermostat
Required R-value Floor Area(sq ft)
❑Packaged System Evaporator Coil .9 •SAFUE COP ❑ R-6 (CZ1,3-7)Ducts Served by system ❑Setback
8' (CZ 16)Ducts s ft (If not already
I__3 Split System Condensing Unit SEER q resent,must
HSPF R-6(al!CZ's)Plenums t P
lkFurnace 3KLineset EER ❑ R-5 or R7.5 Lineset3 be installed)
15
HERS VERIFICATION SUMMARY Installer determines work to be completed and matches to one of the options below. At permit application this
form is allowed to be filled out by hand. For final inspection all forms are to be registered(no hand filled forms allowed)and a copy left on site.
1an1.HVAC Changeout/Repair Required Compliance Documents to be left on site for Final:
4nclude new ducting
All Equipment, CF1R-ALT-02-E
Condenser Unit,Evaporator Coil, CF2R:MECH-01,MECH-20-HERS
Air Handler/Furnace CF3R:MECH-20-HERS
Installer Requirement:Duct leakage(<.15%or,<10%to outside,or seal all accessible leaks)
Exempted from duct leakage testing if:
[11.Duct system registered with HERS provider as previously sealed,or❑2.There is less than 40 linear feet of duct in unconditioned
space,or ❑3.Existing duct systems are constructed,insulated or sealed with asbestos(list manufacture date of building_
❑2.New HVAC System Required Compliance Documents to be left on site for Final:
All new equipment and All New Ducts' CF1R-ALT-02-E
CF2R-MECH-01,MECH-20-HERS,MECH-22-HERS,MECH-(23 or 24)-HERS
CF3R-MECH-20-HERS,MECH-22-HERS,MECH-(23 or 24)-HERS'
Installer Requirement:Duct leakage<6%,Fan Efficacy(.58W/CFM),Air Flow>_350 CFM/ton(or Standards Table 150.0-C/D alternative)
❑3.All New Ducts with Replacement Required Compliance Documents to be left on site for Final:
Includes replacing or installing All New CF1R-ALT-02-E
Ducts'and one or more of the following: CF2R-MECH-01,MECH-20-HERS,MECH-(23 or 24)-HERS
Condenser Unit,Evaporator Coil,Furnace CF3R-MECH-20-HERS,MECH-(23 or 24)-HERS
Installer Requirement:Duct leakage<6%,Air Flow>_350 CFM/ton(or Standards Table 150.0-C/D alternative)
❑ Exempted from duct leakage testing I existing duct systems are constructed,insulated or sealed with asbestos.
❑4.New Ducting over 40 feet Required Compliance Documents to be left on site for Final:
Adding or replacing ducts in unconditioned CF1R-ALT-02-E
space but less than All New Ducts' CF2R:MECH-20-HERS
CF3R:MECH-20-HERS
Installer Required to:Duct leakage(<15%or,<10%to outside,or seal all accessible leaks)
❑ Exempted from duct leakage testing I existing duct systems are constructed,insulated or sealed with asbestos.
All new ducting R-8 required when more than 40 ft installed and R-6 when less than 40 ft installed. This includes in walls,between floors etc.
'A New Duct system is when the duct system is constructed of at least 75 percent new duct material,and up to 25 percent may consist of reused
parts from the dwelling unit's existing duct system(e.g.,registers,grilles,boots,air handler,plenums,duct material.
'R-5(1"thick insulation)for linesets 1"and less. R-7.5(1.5"thick insulation)for linesets over 1 inch. Most mfg will require Suction line Diameter
with insulation as the following 1.5-2T-2%",2.5-3T-21/44",3.5 to 4T-2%",5T-4%"
Contractor(Documentation Author's/Responsible Designer'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 Compliance is true and correct.
2. 1 am eligible under Division 3 of the California Business and Professions Code to accept responsibility for the information on this document.
B. That the energy features and performance specifications for the design identified on this Certificate of Compliance conform to the
requirements of Title 24, Parts 1 and 6 of the California Code of Regulations(CCR).
4. That the energy features and performance specifications,materials,components,and manufactured devices for the building design or
system design identified on this Certificate of Compliance conform to the requirements of Title 24,Part 1 and Part 6 of the CCR.
5. The building design features or system design features identified on this Certificate of Compliance are consistent with the information
provided on other applicable compliance documents,worksheets,calculations,plans and specifications submitted to the enforcement
agency for approval with this building permit application.
Responsible Designparne: Responsible Designer Signature: Date Signed: License:
/' // aL i' / / �'dlZ �Z
Company: Address: City/State/Zip: Phone:
l✓� �� /mc s 2 P.S S� .0Q XA �l61pRa` VG ICS C�0?) 7371.3 —Z
For assistance or questiotW regarding the Energy Standards,contarethe Energy Hotline at:1-800-772-3300
i'
r
OFFICE COPY
COMMUNITY DQYEL0P%4EN7 DEPARTMENT
Bb;t_i SING Di iEION-CUPERTINO
t of Dans and specifications MUST be kept at the
construction. It is unlawful to make any
ci il)n05S or alterations on same,or to deviate
nLs'CiM vni,without approval from the Building Official.
I;e--.'a, oirg of this plan and specifications SHALL NOT P PLANS C ECC .:'
i.,:_ )el id1 to permit or to be an approval of the violation
cf any provision�s�of
any City Ordinance or State Law. DATE
P NNING DEPT
UP,TE C CUPERTINO
PERMIT NO.
1
T7-41-
CERTIFICATE
CERTIFICATE OF VERIFICATION CF3R-MCH-20-H
Duct Leakage Diagnostic Test (P
Project Name: c Kotitg Enforcement Agency: Cupertino Permit Number: B-2016-1945
Building Department
Dwelling Address: 10340 S Blaney Ave City: Cupertino Zip Code: 95014
A.System Informatio
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 No,credit is not taken
(VLLDCS)Credit from CF1R?
05 Verified Low Leakage Air Handling Unit Credit from No,credit is not taken
CF1R?
06 Duct System Compliance Category Alteration
MCH-20d-Complete Replacement or Altered Duct System
B.Duct Leakage DiagnosticTest f_ R" _
01 Condenser Nominal Cooling Capacity(ton) U.S. Emergy Ranters Association
02 Heating Capacity(kBtu/h) 78
03 Conditioned Floor Area served by this HVAC system(ft2) 1506
04 Duct Leakage Test Condition Test final
05 Duct Leakage Test Method Leakage to the outside
06 Leakage Factor .10
07 Air Handling Unit Airflow(AHUAirflow)Determination Heating system method
Method
08 Measured AHUAirflow 0
09 Calculated Target Allowable Duct Leakage Rate(cfm) 169
10 Actual duct leakage rate from leakage test measurement 157
(cfm)
11 Compliance Statement: System passes leikage test
316-A1025378A-M2010530A-M0A Registration Date/Time:2016-05-17 21:34:15 HERS Provider:USERA
Registration Number 2 g /r
CA Building Energy Efficiency Standards Report Version:2013 Rev 1.007 Report Generated:2016-05-17 21:34:27
2013 Residential Compliance Schema Version:2013.1.007
d
CERTIFICATE OF VERIFICATION CF3R-MCH-20-H
Duct Leakage Diagnostic Test (Page 2 of 3)
B.Duct Leakage Diagnostic Test
12 Notes:
h
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 celntral forced air duct system shall not be sealed/taped off during duct leakage
02 testing.OA ducts used for Central Fan IntegIrated(CFI)Indoor Air Quality ventilation systems,or Central Fan Ventilation
Cooling Systems,that utilize dampers that open only when OA is required and automatically close when OA is not required,
may configure the OA damper to the closet`position during duct leakage testing.
l
03 If a complete replacement,all supply and return register boots were sealed to the drywall.
I
04 Building cavities were not used as plenums!or platform returns in lieu of ducts.
05 If cloth backed tape was used it was covered with Mastic and draw bands.
06 All connection points between the air handler and the supply and return plenums are completely sealed.
amr:,a..y_a a•�--,..-..i :-.we.•--�-a..-r..�=... ;;xi �--^;.: ..z.----.-'--^��-.'_.:._ za..-^.a-c7
7 7
If the cyst em complies using th `Smoke Test metho5d,the smoke test was conductedtin'accordance`.witFi the requirements
07 of Reference Residential Appendix RA3,: 3
1.4 .6.Systems that comply using smoke test shall not be included in sample
groups for{HERS verificatiori'compliance. k 7
08 VerificationStatias Pass all applicable requirements are met
09 Correction Notes for this table U.S. Energy Rat rsAl ('dation
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 bejdetermined to be in compliance.
01 Complies:All specified verification protocol requirements on this document are met.
Registration Number:316-A1025378A-M2010530A-M2 A Registration Date/Time:2016-05-17 21:34:15 HERS Provider:USERA
CA Building Energy Efficiency Standards Report Version:2013 Rev 1.007 Report Generated:2016-05-17 21:34:27
2013 Residential Compliance Schema Version:2013.1.007
m _
CERTIFICATE OF VERIFICATION CF3R-MCH-20-H
Duct Leakage Diagnostic Test (Page 3 of 3)
Documentation Author's Declaration State ent
1.1 certify that this Certificate of Verificatio documentation is accurate and complete.
Documentation Author Name: Documentation Author Signature
Minxuan Liu �t%d' 1 !uLl"` ~ —
} -
Company: Date Signed:
Santa Clara HERS 2016-05-17
Address: CEA/HERS Certification Identification(if applicable):
1181 Sundown Ln 410231431
City/State/Zip: Phone:
San Jose CA 95127 408-883-3865
Responsible Person's Declaration statement
I certify the following under penalty of perjury,under the lawsIof the State of California:
1, The information provided on this Certificate of Ve ification is true and correct.
2. 1 am the certified HERS Rater who performed the verification identified and reported on this Certificate of Verification(responsible rater).
3. The installed features,materials,components,manufactured devices,or system performance diagnostic results that require HERS verification
identified on this Certificate of Verification comp)IV with the applicable requirements in Reference Appendices RA2,RA3,and the requirements
specified on the Certificate of Compliance for the Ibuilding approved by the enforcement agency.
4. The info#mation reported'on;applicable s ce Y o s oYthe¢Certlflcate(s)of Installation(CF2R)signed"and submitted by the'peison(s)responsible for the
constructwn'or installation conforms to the"iequi Inents specrfied4on the'Certificate(s)gf Compliance(CUR)approved by the enforcement agency.
5. 1 will ensure that a registered copy of this Certifica e`of Verification shall be-posted or made available iii the building permits)issued for the
building,and,made available-to the enforcement' gen�cy for)all applicable inspections I understand that a`registered copy of�this`Certificate of
Verification is required to be included with the,do umentation the budder provides to.the,bwldin g,owner at occupancy:
f A 3 1- t 3= `
.
`4..�.. mat . { , .
Builder Or Installer Inf�:orion As-Shown O ;,Ae Certificate 0f,- llation '
Company Name(installing Subcontractor,General Contractor,orBuilderg0'0s.: RatersAssociation
Air&Plumbing Systems Inc Energy
Responsible Builder or Installer Name: CSLB License:
Mark Fridlyand 901246
HERS Provider Data Registry Information
Sample Group Number(if applicable): Dwelling Test Status in Sample Group(if applicable)
316-18981 Tested
HERS Rater Information
HERS Rater Company Name:
Santa Clara HERS
Responsible Rater Name: Responsible Rater Signature:
Minxuan Liu
Minxuan Liu(May 17,2016
Responsible Rater Certification Number w/this HERS Provider Date Signed:
410231431 2016-05-17
i Us � ,==3. - I
'This
digital signature:is provided in order to secure
the content of this:regtsteroddocument,and ire no
may implies negistration Provider responsibility for.
�otl i ti�� the accuracy of the information."
Registration Number:316-A1025378A-M2010530A-M2 A Registration Date/Time:2016-05-17 21:34:15 HERS Provider:USERA
CA Building Energy Efficiency Standards Report Version:2013 Rev 1.007 Report Generated:2016-05-17 21:34:27
2013 Residential Compliance Schema Version:2013.1.007
l
SMOKE / CARBON MONOXIDE ALARMS
OWNER CERTIFICATE OF COMPLIANCE
i
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 T ORRE AVENUE• CUPERTINO,CA 95014-3255
CVPERIINC (408)777-3228
l
�
AX(408)777-3333•buildinq@cupertino.org (�t
Permit No.
Address #of Alarms Smoke: 7 Carbon Monoxide:
PERMI7C CANNOT- EFINAI,ED AND COMPLETED UNTIL THIS CERTIFICATE
' HAS BEEN, AND TTIRNED TO TiA�.BUILDING DIVISION
PURPOSE
This affidavit is a self-certification for the installation of all required Smoke and Carbon Monoxide Alarms for ..
compliance with 2013 CRC Section R314; 2013 CBC Sections 420.6 and 907.2.11.2 where no interior access for
inspections are required.
GENERAL INFORMATION
Existing single-family and multi-family dwellings shall be provided with Smoke Alarms and Carbon
Monoxide alarms. When the valuation of additions, alterations,or repairs to existing dwelling units exceeds
$1000.00, CRC Section R314 and.CBC Sections 907.2.11.5 and 420.6 require that Smoke Alarms and/or Carbon
Monoxide Alarms be installed in the following locations:
AREA SMOKE ALARM_ CO ALARM
Outside of each separate sleeping area in the immediate vicinity of the X X
bedroom(s)
On every level of a dwelling unit including basements X _ X
Within each sleeping room X
Carbon Monoxide alarms are not required in dwellings which do not contain fuel-burning appliances and that
do not have an attached garage. Carbon monoxide alarms combined with smoke alarms shall comply with
CBC Section 420.6 and shall be approved by the Office of the State Fire Marshal.
Power Supply:In dwelling units with no commercial power supply, alarm(s)may be solely battery operated.
In existing dwelling units, alarms are permitted to be solely battery operated where repairs or alterations do
not result in the removal of wall and ceiling finishes or there is no access by means of attic,basement or crawl
space.Refer to CRC Section R314 and CBC Sections 907.2.11.4 and 420.6.2.An electrical permit is required for
alarms which must be connected to the building wiring.
As owner of the above-referenced property,I hereby certify that the alarm(s) referenced above has/have been
installed in accordance with the manufacturer's instructions and in compliance with the California Building
and California Residential Codes. The alarms have been tested and are operational, as of the date signed
below.
I have read and agree to comply with the terms and conditions of this statement
Owner(or Owner Agent's)Name:
1\ 1'G®IGiS Q n Signature............ ...............� ... ..............................Date:
Contractor Naine:
Signature...................................................................Lic.#......................................Date: ...................
Smoke and CO for-nn.doc revised 03118114
I
i
WATER-CONSERVING PLUMBING FIXTURES
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
1
GUPERTtNQ 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255
` J (408)777-3228•FAX(408)777-3333• building(a.cupertino.org 22 p
Owner Name /Vr�Lr)/a S l! CD Vit-I Yernit No. 13 _ 2(0 �6
Address 1 V S LIo S . b i n vle &
1. Is your real property a registered historical site?
❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form.
M"No Go to Question 2.
2. Does your real property have a licensed plumber certifying that,due to the age or configuration of the property or its
plumbing,installation of water-conserving plumbing fixtures is not technically feasible?
❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply.
❑ The licensed plumber's certification has been provided to the Building Division.
Skip the rest of the form and sign bottom of form.
W(No Go to Question 3.
3. Is water service permanently disconnected for your building?
❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form.
VNo Go to Question 4.
4. Is your real property built and available for use or occupancy on or before January 1, 1994?
❑ No My real property is built and available for use or occupancy after'January 1, 1994.
� e Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form.
119 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..
5. PI ase check ONE of the following:
My property is a single-family residential real property. See Civil Code Section 1101.4.
On and after January 1, 2014, building alterations or improvements shall require all non-compliant plumbing fixtures
to be replaced with water-conserving plumbing fixtures throughout the building.On or before January 1,2017,all non-
compliant plumbing fixtures shall be replaced with water-conserving plumbing fixtures (regardless of whether
property undergoes alterations or improvements).
❑ My property is a multifamily residential real property. See Civil Code Section 1101.5.
On and after January 1,2014,specified building alterations or improvements shall require non-compliant
plumbing fixtures to be replaced with water-conserving plumbing fixtures.
On or before January 1,2019,all non-coinpliant 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 commercial real property. See Civil Code Section 1101.5.
On and after January 1,2014,specified building alterations or improvements shall require non-compliant
plumbing fixtures to be replaced with water-conserving plumbing fixtures.
On or before January 1, 2019, all non-compliant plumbing fixtures shall be replaced with water- conserving
plumbing fixtures throughout the building(regardless of whether property undergoes alterations or improvements).
I,as the owner or owner's agent of this property,certify under penalty of perjury that non-cornpliant 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 Building Standards Code,and manufacturer's
installation requirements,and that the water-conserving plumbing fixtures comply with the requirements as indicated in the
table on the following page.
Owner or Owner Agent's Signature: /��'. !�/� j Date: 1 6
Upon completing and signing this Certificate,please return it to the Building Division in order to final your building permit.
SB4072015.doc revised 08126115
BUILDING PERMIT CANNOT BE FINALED AND.COMPLETED UNTIL THIS
' ' CERTIFICATE HAS BEEN°SIGNED AND RETURNED TO T-�1 BUILDING DIVISION
Non-Compliant Water-Conserving Plumbing Fixture
Plumbing Fixturel (Fixture Complying with Current Code Applicable to New Construction)
Maximum Water Usage/Flow Rate
Fixture Type 2013 CPC Ch. 4 2013 CPC Ch. 4 2013 CPC Ch.4
Water Usage 2013 CALGreen Div. 4.3 2013 CALGreen Div. 4.3 2013 CALGreen Div. 5.3
/Flow Rate 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 0.5 gallons/flush
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.doc revised 08126115