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15010036CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10282 MENHART LN CONTRACTOR: D&D CONSTRUCTION PERMIT NO: 15010036 AND DEVELOPMENT OWNER'S NAME: BROBERG ROBERT NEAL III AND SAN W PO BOX 3565 DATE ISSUED: 04/09/2015 OWNER'S PHONE: 4087720715 FREMONT, CA 94539 PHONE NO: (510) 579-2353 JOB DESCRIPTION: RESIDENTIAL COMMERCIAL ❑ LICENSED CONTRACTOR'S DECLARATION CONSTRUCT (N) 2 STORY SFD (2174 SQ FT); ATTACHED License Class_ _ Lic. # � 3 �G Z S GARAGE (422 SQ FT); PORCHBALCONY (279 SQ FT). Contractor Lk Date_494 J I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain a certificate of consent to self-insure for Worker's ompensation, as provided for by Section 3700 of the Labor Code, for the valuation: $400000 p rformance of the work for which this permit is issued. Sq. Ft Floor Area: 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 APN Number: 37517016.00 Occupant), TN PC: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct. I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction, and hereby authorize representatives of this city to enter 180 DAYS FRO T CALLED INSPECTION. 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 Issued by Date: r granting of this permit. Additionally, the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code, Section 9.18. _ RE-ROOFS: Date (� All roofs shall be inspected prior to any roofing material being installed. If a roof is Signature installed without first obtaining an inspection, I agree to remove all new materials for inspection. ❑ OWNER-BUILDER DECLARATION Signature of Applicant: Date: I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER I, as owner of the property, or my employees with wages as their sole compensation, do the work, and the structure is not intended or offered for sale (Sec.7044, will Business & Professions Code) I, as owner of the property, am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project (Sec.7044, Business & Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Code, Section 25532(a) should I store or handle hazardous declarations: I have and will maintain a Certificate of Consent to self-insure for Worker's Health & Safety material. Additionally, should I use equipment or devices which emit hazardous Compensation, as provided for by Section 3700 of the Labor Code, for the air contaminants as defined by the Bay Area Air Quality Management District I compliance with the Cupertino Municipal Code, Chapter 9.12 and performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance, as provided for by will maintain & Safety aety Code, Sections 25 5, 25533, and 25534. f the Health! Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized agent: Dater l permit is issued. I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Worker's CONSTRUCTION LENDING AGENCY Compensation laws of California. If, after making this certificate of exemption, I I I hereby affirm that there is a construction lending agency for the performance of become subject to the Worker's Compensation provisions of the Labor Code, must work's for which this permit is issued (Sec. 3097, Civ C.) forthwith comply with such provisions or this permit shall be deemed revoked. Lender's Name APPLICANT CERTIFICATION Lender's Address 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 ARCHITECT'S DECLARATION indemnify and keep harmless the City of Cupertino against liabilities, judgments, expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. costs, and granting of this permit. Additionally, the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code, Section Licensed Professional 9.18. Signature Date C3i12_4:i #I:ti7 CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION h 10300 TORRE AVENUE • CUPERTINO, CA 950143255 �n U (408) 777-3228 • FAX (408) 777-3333 • building(a,)cupertino.org M NAW CONSTRI iCTION M ADDiTiON n ALTERATION / TI I—I REVISION /DEFERRED ORIGINAL PERMIT # PROJECT ADDRESS o Z 62- l I HAn T 40 APN # '3 -? Iy- OWNER NAME Robex7 RPp g�Cr PHONE 4�77.Z 0715 OW E-MAIL R(320 fj�21Cs @(rMAII• STREET ADDRESS 102 %Z til etJ HART L 1 v • CITY, STATE, zip f /J ptjnp _r4O FAX CONTACT NAME r A A � 1 Y HV /' /rGi"! l V (r' Zv PHONE //O b S4,2 "7 C Q 7 E-MAIL F /1 a Kr L140 �a.M 1� rTV Q YA t4Wo• STREET ADDRESS I Ztf %0 $/►rtlliT66A AJC. CITY, STATE, ZIPSAW00k f CAg5O7Q /ENGINEER FAX 11 OWNER ElOWNER-BUILDER 11 OWNER AGENT El CONTRACTOR 11 CONTRACTOR AGENT X ARCHITECT ❑ ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE CHIT GINEER NAME S /►A (1 C A 5 �. t Or /nom !� nNF1�+, LICENSE NUMBER e, 2 9 %" G O O_� BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK N�• 4 1 /� �/^ Z S 10rU` S (jam r•ogf -% ` t45W-217 2 ?q S F EXISTING USE S FfL PROPOSED USE CONSTR. Q Fa TYPE #STORIES 4"P46 -2 -USE TYPE OCC. SQ.FT. VALUATION ($) XISTO AREAL 1 %70 AREA ?.SqSq DEMO AREA f 37 TOTAL //0 NET AREA 2.59 (0 BATHROOM REMODEL AREA KITCHEN REMODEL AREA OTHER REMODEL AREA PORCH AREA 20'& I DECK AREA -71 TOTAL DECK/PORCH AREA GARAGE AREA: DETACH if -2y OtA7'TACH # DWELLING UNITS: IS A SECOND UNIT ❑ YES BEING ADDED? ;J NO SECOND STORY MYES ADDITION? ❑ NO PRE -APPLICATION XlYES IF YES, PROVIDE COPY OF PLANNING APPL # NO PLANNING APPROVAL LETTER ISTHE BLDG AN E] YES EICHLER HOME? JRNO TOTAL VALUATION: 40d o0 0 By my signature below, I certify to each of the following: I am the property owner or autho o 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 relating to building construction. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes. Signature of Applicant/Agent: if, 0 Date: �r O7J -2c�� SUPPLEMENTAt INFORMATION REQUIRED _ New SFD or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building permit for new building. _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure form if any Hazardous Materials are being used as part of this project. —Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application. PLAN CHECK TYPE ROUTING SLIP ❑ OVER-THE-COUNTER ❑ EXPRESS ❑ STANDARD ❑ LARGE ElMAJOR ❑ BUILDING PLAN REVIEW ❑ PLANNING PLAN REVIEW ❑ PUBLIC WORKS ❑ FIRE DEPT ❑ SANITARY SEWER DISTRICT ❑ ENVIRONMENTAL HEALTH BldgApp_2011.doc revised 06/21/11 M CITY OF CUPERTINO WNW 10M F c'rnvr A TnR - RI TII .DING DIVISION OCCUPANCY TYPE: 1' 1J 1J ADDRESS: 10282 MENHART LN DATE: 01/07/2015 REVIEWED BY: MELISSA PC FEE ID APN: 375 17 016 13P#:Z��p *VALUATION: $400,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: New Construction PRIMARY USE: SFD or Duplex 2nd Unit? Yes No PENTAMATION 1 R3SFDW PERMIT TYPE: i WORK CONSTRUCT N 2 STORY SFD WITH 2,174 LIVING SPACE 422 S.F. ATTACHED GARAGE & 279 SCOPE S.F. PORCH/BALCONY OCCUPANCY TYPE: TYPE OF CONSTR. FLR AREA s.f. PC FEES PC FEE ID BP FEES 11P FEE ID R-3 (Custom) II-B,III-B,IV,V-B 2,596 $2,984.61 1R3PLNCK $2,821.63 IR3INSP $0.00 PME Plan Check: $0.00 Permit Fee: $2,821.63 Suppl. Insp. Fee -.0 Reg. Q OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 TOTALS: 2,596 $2,984.61 Construction Tax: IBCONSTAh"R $2,821.63 new units NOTE: This estimate does not include fees due to other Departments (i.e. rtannmg, ruauc rr urns, 1 -tie, aurtit—y .,—...•�•• •�•, ��••��- _ __ _ _ L --_,a •L r.. ..� nAnn nvnitnhta and Oro nnly an estimate. Contact the Dept for addn'l Info. Ulstrtci, etc . tnese Lees awe uuoeu or, eiw r«ina, FEE ITEMS (Fee Resolution 11-053 Eff 7 1 13) ».»••...,_., FEE _.._ _. - QTY/FEE ____ ___-__----. _ MISC ITEMS Plan Check Fee: $2,984.61 Select a Misc Bldg/Structure or Element of a Building Suppl. PC Fee: Q Reg. Q OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $2,821.63 Suppl. Insp. Fee -.0 Reg. Q OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Tax: IBCONSTAh"R 1 new units $670.76 -�L132?TI7,�'11"iiifCc? 1` i': O 0 Work Without Permit? Yes Q No $0.00 Advanced Planning Fee: IPLLONGR $363.44 Select a Non -Residential Building or Structure e Q A utnenlatiort Fce,s, Strong Motion Fee: IBSEISHICR $52.00 Select an Administrative Item Bld,p Stds Commission Fee: 1BCBSC $16.00 SUBTOTALS: $6,908.44 $0.00 TOTAL FEE: $6,908.44 Revised: 01/06/2015 AUG -10-2015 23:12 From: To:14087773333 Paee:1,11 Builduig Department City Of capeltino 10300 Terre Avenue Cupertino, CA 95014-3255 Tcicph onc: 408-777-3228 CUPERT1NO Fal.: 408-777-3333 CONTRACTOR / SUBCONTRACTOR I.,IST -- ........... - - JOB ADDRESS:10289 Menhart Ln, Cupertino, CA PERMIT # 14050170 OWNER'S NAMR: Mlsha Dragojevic 4 408-355-3971 G.F,NERAL CONTRACTOR.- 8 Plus, INC. LiUSIN_E_SS LICENSE 0 636132 ADDR2 ESS: 242 Commercial St CTIY/7,TPC0DE: Sunnyvale / 94085 "Our municipal cock requires all businesses worldng in the city to have a City of Cupertino business license, NO .BUILDING FINAJ,, OR FINAL. OCCUPANCY INSPECTION(S) WILL RE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALT. SUSCO TRACTO tS HAVE OBTAINED A CITY OF CUPERTI.NO BUSINESS LWENSE. I am not using any subcontractors: Sig , ture Date Please check applicable subcontractors and complete the following hiformation: O+vner / Contractor signature Date SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE 9 - ._... Cabinets & Millwork ------------- ..._...._..._ __ _ ....... _ . Cement Finishing Electrical rxcavatiou. Fencing Flooring / Carpeting _ Linoleum /Wood Glass/ Glazing Heating l.nsulatl oll Landscaping Latlling-- V Masonry Painting / Wallpaper Paving Pl.asteri.ng Plumbing Roofing Septic Tank Sheet. Metal Shcu Rock ..Tile O+vner / Contractor signature Date Building Department 1\( City Of Cupertino LU 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR / SUBCONTRACTOR LIST JOB ADDRESS: ( &ZSZ YA.e aha 1-0 PERMIT# 050t®0310 OWNER'S NAME: ?->?_6berA PHONE # 9(o - S'7 Z3 53 GENERAL CONTRACTOR: �o"O Ku kV Cvh6khxc-A' SINESS LICENSE # V ADDRESS: pirmy, ;Siq eA gAt3 CITY/ZIPCODE: 453 *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL , CCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Signature Date Please check applicable subcontract rs and complete the following information: Owner / Contractor Signature Date SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Ger` e-w�-gl o Electrical Excavation Fencing Flooring / Carpeting Linoleum / Wood Glass / Glazing Heating I- t;T'L 5 Air Ca rQ- �{ o Insulation Landscaping Lathing Masonry Painting / Wallpaper Paving Plastering 39731 Plumbing Roofing w�-c v �O ``, ,N J# Z 13 i -7 Septic Tank Sheet Metal Sheet Rock Tile Owner / Contractor Signature Date CUPERTINO PURPOSE UTILITY RELEASE REQUEST FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildincIO-cupertino,org For residential single family or duplex construction, there are cases where gas and electric utilities are requested to be released prior to the issuance of the certificate of occupancy. Upon approval from the building inspector, the City of Cupertino is allowing both utilities to be released prior to the final sign -off of the building. INSTRUCTIONS 1. Download this form at: littp://www. cupenino.org/index.aspx?pale-297. 2. Complete the form and obtain signatures from both the owner of the property and the primary contractor. 3. Fax, E -Mail, Mail or hand deliver the original signed form to: City of Cupertino Building Division Attn: Utility Release Request Form 408-777-3228 office 10300 Torre Ave. 408-777-3333 fax Cupertino, CA 95014 buiIdin glli cupertino.org 4. Schedule a Gas Meter Release inspection (#403) and/or Electric Meter Release inspection (4404). Please note, a Gas Test inspection (#506) is required prior to or at the same time of the Gas Meter Release inspection. BUILDING INFORMATION (Please complete the following information): APN / BLDG PERMIT* DATE: - �Iz ell SITE ADDRESS: 50 OWNER'S NAME: PHONE #: p'e FAX #: MAILING ADDRESS (if different from site address): CONTRACTOR: PHONE #: o v FAX #: CONTACT: PHONE M FAX* I request the City to release my utilities prior to obtaining a final inspection approval for the building. I fully understand the occupants of the building cannot move into the residence until they receive all of the required final sign -offs and the City has issued a certificate of occupancv for the 4uildina, Owner: ............................................. Print:... a.0 . .. ........................... Date: ..�1. %.. / ........1. Contractor:......... .......... Print: ... Date:2% ..,7/ 1171 v moo/ Ut11ityRe1easeF6nn_2011.doc revised 08109/11 FIL CALGREEN SIGNATURE DECLA)YRI Project Name- BROBERG AND SAN RESIDENCEONS Project Address--'"'�"' -"--•------ 10282 MENNART LANE Project Description New 2 storioS building with 2,174sf living andel 422sf garage SECTIOND1 ESIGN VERIFICATION Complete all lines of Section 1 - Design Verification' and submit the cor"pleted checklist (Columns 1 and 2 with h pians and building permit application to the Building Department to The owner and design professior,�J responsible for compliance with CalGreen Standards have revised (he plans an certify that the items checked Project in accordance with the bove are hereby incorporated into the project plans and will be implemented into the adopted by the City of Cupertinrequirements set forth in the 2013 California Green Building Standards Code as Owners Signature -- " ROBERT BROBERG AND ENDY SAN -------____._._------- Owner's Name (Please Pr;rt; Designrofess,onai s Signature12/29/2014 .............. FRANK LINH HO —� ----------- Date Design Professional s Nan: e ,Pease P, incl Signature of E!cerise Prrtess cna, r= —�' _spc sible for CalGreen compliance- -_�L2 �_ ............ Name of License Professional resper,s,b for CalGreen coin lance 'P! - — __ _. �� t p' t ease P•mij4.I Sa' Phone _ Ematl Address for License Prcfes , of ons,bie forCalGreen compliance SECTION —2— IMPLEMENTATION VERIFICATION Complete, sign and submit the competed checklist, including column 3, together with all original signatures on 2 to the Budding Department prior to Building Department final inspection. Section I have inspected the work and have received sufficient documentation to verify and certify that the Project :den tified above was constructed in accordance with this Green Bu,ld,n the 2013 California Green Buildin g Checklist and ,n accordance with the requirements of g Standards Code as adopted by the City of Cupertino Signature of (,cense prof ss;onai responsible for CalGreen compliance ---- ^i/� IJ \ Date Name of license Professional respons ae for p, tJ � CalGreen comGnance {Please Print) �� 4' l ��tl`�"V-D Phone Email Address for license rotess,onal rest, 'Onsble for -F alGreen comp,iance Page i ,,I' 5 INSTALLATION CERTIFICATE r age 1 of 12) CF -6R Site Address Permit umber i nv,wI i bds - Installation certificates (CF -6R) are required for each and every dwelling unit. When the installs 'on of measures that require field verification and diagnostic testing is complete, the builder or the builder's subcontractor sh 1 complete diagnostic testing and the procedures specified in this section. When the installation is complete, the buildej or the builder's subcontractor shall complete the CF -6R (Installation Certificate), and keep it at the building site 7or review by the building department. The builder also shall provide a copy of the Installation Certificate to the HERS rate for any measures requiring field verification and diagnostic testin , er Section 10-103 a . Tl TT A TT -k Tf! GFX%CST A4Q W a I Alt r1rti 111N V J 1 J 11 V.L1 3. Distribution CEC Certified Type If Heater M& Name & (Std, Point- Recirculation, T Model Number of -Use, etc Control T h # of Identical Systems Rated Input (kw °� Tank Volume E Buvbr) (gallons)(E External S�� Insulation eietwy Y ; RE)2 Loss (%)2 R-value2 Date: 6-13 -( b 1 C � GD trD 1 For small gas storage (rated input of less than or equal to 75,000 Btu/hr), electric resistant heaters, list Energy Factor (EF). For large gas storage water heaters (rated input of greate Recovery (RE), Thermal Efficiency, Standby Loss and Rated Input. For instantaneous gas Efficiency and Rated Input. 2. R-12 external insulation is mandatory for storage water heaters with an energy factor of less and heat pump water han 75,000 Btu/hr), list ate +r heaters, list Thermal 10.58. Kitchen Piping: If indicated on the CF -1 R, all hot water piping >_ 3/4 inches in diameter that runs from the howater source t the kitchen fixtures is insulated. Faucets & Shower Heads: All faucets and showerheads installed are certified to the Energy Commission, pursuant to Tike 24, Part 6, Section 111. Central Water Heating in Buildings with Multiple Dwelling Units (required for prescriptive ❑All hot water piping in main circulating loop is insulated to requirements of § 1500) 1 ❑Central hot water systems serving six or fewer dwelling units which have (1) less than 25 of distribution piping outdoors; (2) zero distribution piping underground; (3) no recirculation pump; and (4) insulal 'on on distribution piping that meets the requirements of Section 1500) ❑Central hot water systems serving more than 6 dwelling units - presence of either a time c trol or a time/temperature control ✓ 106 I, the undersigned, verify that equipment listed above my signature is: 1) the ac al equipment installed; 2) equivalent to or more efficient than that specified in the certificate of compliance (Form CF -1 'submitted for compliance with the Energy Efficiency Standards for residential buildings; and 3) equipment that meets exceeds the appropriate requirements for manufactured devices (from the Appliance Efficiency Regulations or Part 6), where. applicable. Installing Subcontractor (Co. Name) OR General Contractor (Co. Name) OR Owner Signature: Date: 6-13 -( b Copies to: BUILDING DEPARTMENT, HERS RATER (IF APPLICABLE) BUILDING OWNER OCCUPANCY Residential Compliance Forms ! September 2005 INSTALLATION CERTIFICATEPaee 2 of 121 CF -6R Site Aaaress Zvf!92- 'i1W. t1 M -t+ � - u l at V ('-A , Permit Number / fT�0 I& 07� to An installation certificate is required to be posted at the building site or made available for all a information provided on this form is required) After completion final inspection, propriate inspections. (The of a copy musi department (upon request) and the building owner at occupancy, per Section 10-103(a). be provided to the building FENESTRATION/GLAZING: Manufacturer/Brand Name Total 1 i Quantity of Area (GROUP LIKE Product U -factor Product SHGC # of Like Product Square Item RODUCTS) (< CF -1 R value) 2 (5CF-1 R value) 2 Panes Exterior Shading Device Comments/Location/ (Optionao (OptionFeet 1. or Overhang Special Features 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12E5.14 tl Use values from a fenestration product's NFRC label. For fenestration products without an NJ values from Section 116 the Energy RC label, use the default of Efficiency Standards. 2) Installed U -factor must be less than or equal to values from CF -1R. Installed SHGC must be 1 from CF -1R, or a shading device (exterior or overhang) is installed ss than or equal to values as specified on the CF -1R weighted average U -factors for the total fenestration area are less than or equal to values from Alternatively, installed CF If SHGC values from § 116 identify whether tinted or not. -1R. using default table ✓ W I, the undersigned, verify that the fenestration/glazing listed above my signature: 1 product installed, 2) is equivalent to has lower is the actual fenestration or a U -factor and lower SHGC than that spetified compliance (Form CF -1R) submitted for compliance with the Energy Efficiency Standards fo in the certificae of residential buildingstand 3) the product meets or exceeds the appropriate requirements for manufactured devices (from P Eirt 6), where applicable. Item #s Signature Date Installing Subcontractor (Co. N (if applicable) e) OR General Contractor (Co. Name) OR Owner OR Window Distributor OR Item #s (if applicable) Signature Date Installing Subcontractor (Co. Kai rie) General Contractor (Co. Name) OR Owner OR Window Distributor ) OR ing Subcontractor (Co. Na Item #s Signature D7Ge�neral (if applicable) Contractor (Co. Name) R Owner indow is Copies to: Building Department, HERS Rater (if applicable) Building Owner at Occupanc Residential Comvliance Formc April 2005 INSTALLATION CERTIFICATE Page 3 of 12) CF -6R Site Address ---[Permi Number 1.029 a., M"?.ar# GQ- k5o / oa 36' An installation certificate is required to be posted at the building site or made available for all appropriate inspections. (The information provided on this form is required) After completion of final inspection, a copy mus be provided to the building department (upon request) and the building owner at occupancy, per Section 10-103(a). HVAC SYSTEMS: Heating Equipment Equip Type (pkg. heat um CEC Certified Mfr. Name and Model Number # of Identical S stems>_CF-1R Efficiency (AFUE, etc.) value) Duct Location attic, etc. Duct o Piping R-valu Heating Load tu/hr Heating Capacity tu/hr C ig o� i 1 4^0e a-t�'�c. R Aak (� K rye Var,c�hl� prd Cooling Equipment Equip Type (pkg. heat um CEC Certified Mfr. Name and Model Number # of Identical Systems Efficiency � (SEER or EER) >_CF -IR value) Duct Location attic, etc. Duct R -value Cooling Load 4BE C %ryaA 1 4^0e T (� C AY Var,c�hl� prd 1. > symbol reads greater than or equal to what is indicated on the CF -IR value. Include both SEER and EER if compliance credit for high EER air conditioner is ✓ 011, the undersigned, verify that equipment listed above is: 1) is the actual equipment installed, 2) equivalent to or more efficient than that specified in the certificate of compliance (Form CF -1R) submitted for compliance with the Energy Efficiency Standards for residential buildings, and 3) equipment that meets or exceeds the appropriate requirements for manufactured devices (from the Appliance Efficiency Regulations or Part 6) where applicable. Installing Subcontractor (Co. Name) OR General Contractor (Co. Name) OR Owner Signature: Date: ._ 1 Copies to: BUILDING DEPARTMENT, HERS RATER (IF APPLICABLE) BUILDING OWNER Residential Compliance Forms OCCUPANCY April 2005 I INSTALLATION CERTIFICATE Page 12 of 12) CF -6R Site Addressnn AA,, Permi Number 10 2 � i.�� W� 'eft 1,sC,16p3 County Subdivision Lot N ber Description of Insulation (Formerly IC -1 Form) 1. RAISED FLOOR Material n 1 �5 Thickness (inches) 2. SLAB FLOOR/PERIMETER Material Thickness (inches) Perimeter Insulation Depth (inches) 3. EXTERIOR WALL Frame Type ZX - A. Cavity Insulation Material Thickness (inches) — B . Exterior Foam Sheathing Material Thickness (inches) 4. FOUNDATION WALL Material Thickness (inches) Brand Name 0 ,q�5 z a t. yr I Thermal Resistance (R -Valu) Brand Name Thermal Resistance (R -V Brand Name Thermal Resistance (R-Valuj) Brand Name Thermal Resistance (R -V Brand Name Thermal Resistance (R -V 5. CEILING + (� Batt or Blanket Type .r�1P 4 Brand Name bW Thickness (inches) ( Thermal Resistance (R -Vali; Loose Fill Type Brand Contractor's min installed weight/ft2 lb Minimum thickness Manufacturer's installed weight per square foot to achieve Thermal Resistance (R- 6. ROOF &C�\rV% �" sw 5 Gt9rt- 113 Material Brand Name Thickness (inches) Thermal Resistance,(R-Valu ) Declaration In I hereby certify that the above insulation was installed in the building at the above locati n in conformance with the t Energy Efficiency Standards for residential buildings (Title 24, Part 6, California Code of Regulations) as indicated _ on the Certificate of Compliance, where applicable. Item #s (if applicable) Signature Date �..I Installing Subcontractor (Co.Name) General Contractor (Co. Name OR Window Distributor OR I OR Owner Item #s Signature Date Installing Subcontractor (Co. ame) OR (if applicable) General Contractor (Co. Name i OR Owner OR Window Distributor Item #s Signature Date Installing Subcontractor (Co. ame) OR (if applicable) General Contractor (Co. Name OR Owner OR Window Distributor Residential Compliance Forms April 2005 FIL. CERTIFICATE OF VERIFICATION CF3R-MCH-20-H Duct Leakage Diagnostic Test ' (Page 1 of 3 ) Project Name: Broberg Residence Enforcement Agency: City of Cupertino Permit Number: Dwelling Address: 10282 Menhart Lane City: Cupertino Zip Code: 95014 A. System Information 01 Space Conditioning System Identification or Name System one 02 Space Conditioning System Location or Area Served 800 03 Building Type from CF -1R Single family 04 Verified Low Leakage Duds in Conditioned Space (VLLDCS) Credit from CF1R? No, credit is not taken 05 Verified Low Leakage Air Handling Unit (VLLAHU) Credit from CF1R? No, credit is not taken 06 j Duct System Compliance Category New MCH -20a - Completely New Duct System B. Duct Leakage Diagnostic Test O1 Condenser Nominal Cooling Capacity (ton) 0 02 Heating Capacity (kBtu/h) 58 03 Conditioned Floor Area served by this HVAC system (ft2) 800 04 Duct Leakage Test Condition Test final 05 Duct Leakage Test Method Total leakage 06 Leakage Factor 0.06 07 Air Handling Unit Airflow (AHUAirflow) Determination Method Heating system method 08 Measured AHUAirflow This field or section is not applicable 09 Calculated Target Allowable Duct Leakage (cfm) 76 10 Actual duct leakage rate from leakage test measurement (cfm) 75 11 Compliance Statement System passes leakage test Registration Number: 216-A0187708A-M2000001A-M20A Registration Date/Time: 2016-05-19 15:22:58 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.007 Report Generated: 2016-05-19 15:22:08 2013 Residential Compliance Schema Version: 2013.1.007 CERTIFICATE OF VERIFICATION CF3R-MCH-20-H Duct Leakage Diagnostic Test (Page 2 of 3 ) B. Duct Leakage Diagnostic Test 12 Notes C. Additional Requirements for Compliance 01 System was tested in its normal operation condition. No temporary taping allowed. 02 Outside air (OA) duct connections to the central forced air duct system shall not be sealed/taped off during duct leakage testing. OA ducts used for Central Fan Integrated (CFI) Indoor Air Quality ventilation systems, or Central Fan Ventilation Cooling Systems, that utilize dampers that open only when OA is required and automatically close when OA is not required, may configure the OA damper to the closed position during duct leakage testing. 03 All supply and return register boots were sealed to the drywall. 04 Building cavities were not used as plenums or platform returns in lieu of ducts. 05 If cloth backed tape was used it was covered with Mastic and draw bands. 06 All connection points between the air handler and the supply and return plenums are completely sealed. Visual Inspection at Final Construction Stage (applicable if system was tested at rough -in) After installing the interior finishing wall and verifying that the above rough -in tests was completed, the following procedure must be performed 07 For all supply and return registers, verify that the spaces between the register boot and the interior finishing wall are properly sealed. 08 If the house rough -in duct leakage test was conducted without an air handler installed, inspect the connection points between the air handler and the supply and return plenums to verify that the connection points are properly sealed. 09 Inspect all joints to ensure that no cloth backed rubber adhesive duct tape is used. 10 Verification Status Pass 11 Correction Notes for this table The responsible persons signature on this compliance document affirms that all applicable requirements in this table have been met unless otherwise noted in the Verification Status and the Corrections Notes in this table. D. Determination of HERS Verification Compliance All applicable sections of this document shall indicate compliance with the specified verification protocol requirements in order for this Certificate of Verification as a whole to be determined to be in compliance. O1 Complies: All specified verification protocol requirements on this document are met. Registration Number: 216-A0187708A-M2000001A-M20A Registration Date/Time: 2016-05-19 15:22:58 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.007 Report Generated: 2016-05-19 15:22:08 2013 Residential Compliance Schema Version: 2013.1.007 CERTIFICATE OF VERIFICATION CF3R-MCH-20-H Duct Leakage Diagnostic Test (Page 3 of 3 ) Documentation Author's Declaration Statement 1. 1 certify that this Certificate of Verification documentation is accurate and complete. Documentation Author Name: Documentation Author Signature: �/++ ��++ on,5 Long Le aL -Ce Company: Date Signed: LOTUS AIR CARE 2016-05-19 15:22:41 Address: CEA/ HERS Certification Identification (if applicable): 909 EAST HOMESTEAD ROAD City/State/Zip: Phone: SUNNYVALE CA 94087 408-892-6537 Responsible Person's Declaration statement I certify the following under penalty of perjury, under the laws of the State of California: 1. The information provided on this Certificate of Verification is true and correct. 2. 1 am the certified HERS Rater who performed the verification identified and reported on this Certificate of Verification (responsible rater). 3. The installed features, materials, components, manufactured devices, or system performance diagnostic results that require HERS verification identified on this Certificate of Verification comply with the applicable requirements in Reference Appendices RA2, RA3, and the requirements specified on the Certificate of Compliance for the building approved by the enforcement agency. 4. The information reported on applicable sections of the Certificate(s) of Installation (CF2R) signed and submitted by the person(s) responsible for the construction or installation conforms to the requirements specified on the Certificate(s) of Compliance (MR) approved by the enforcement agency. 5. 1 will ensure that a registered copy of this Certificate of Verification shall be posted, or made available with the building permit(s) issued for the building, and made available to the enforcement agency for all applicable inspections. I understand that a registered copy of this Certificate of Verification is required to be included with the documentation the builder provides to the building owner at occupancy. Builder Or Installer Information As Shown On The Certificate Of Installation Company Name (Installing Subcontractor, General Contractor, or Builder/Owner): Responsible Builder or Installer Name: CSLB License: HERS Provider Data Registry Information Sample Group Number (if applicable): Dwelling Test Status in Sample Group (if applicable) Tested HERS Rater Information HERS Rater Company Name: Builders' Energy Services, Inc. Responsible Rater Name: Responsible Rater Signature: Darrel Kelly Responsible Rater Certification Number w/ this HERS Provider: Date Signed: CC2005655 !fid 2016-05-19 15:22:58 Digitally signed by CaICERTS. This digital signature is provided in order to secure the content of this registered document, and in noway implies Registration Provider responsibility for the accuracy of the information. Registration Number: 216-A0187708A-M2000001A-M20A Registration Date/Time: 2016-05-19 15:22:58 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.007 Report Generated: 2016-05-19 15:22:08 2013 Residential Compliance Schema Version: 2013.1.007 CERTIFICATE OF VERIFICATION CF3R-MCH-20-H Duct Leakage Diagnostic Test (Page 1 of 3 ) Project Name: Broberg Residence Enforcement Agency: City of Cupertino Permit Number: Dwelling Address: 10282 Menhart lane City: Cupertino Zip Code: 95014 A. System Information 01 Space Conditioning System Identification or Name System two 02 Space Conditioning System Location or Area Served upper level 03 Building Type from CF -1R Single family 04 Verified Low Leakage Ducts in Conditioned Space (VLLDCS) Credit from CF1R? No, credit is not taken 05 Verified Low Leakage Air Handling Unit (VLLAHU) Credit from CF1R? No, credit is not taken 06 Duct System Compliance Category New MCH -20a - Completely New Duct System B. Duct Leakage Diagnostic Test O1 Condenser Nominal Cooling Capacity (ton) 0 02 Heating Capacity (kBtu/h) 39 03 Conditioned Floor Area served by this HVAC system (ft2) 800 04 Duct Leakage Test Condition Test final 05 Duct Leakage Test Method Total leakage 06 Leakage Factor 0.06 07 Air Handling Unit Airflow (AHUAirflow) Determination Method Heating system method O8 Measured AHUAirflow This field or section is not applicable 09 Calculated Target Allowable Duct Leakage (cfm) 51 10 Actual duct leakage rate from leakage test measurement (cfm) 34 11 Compliance Statement System passes leakage test Registration Number: 216-A0187750A-M2000001A-M20A Registration Date/Time: 2016-05-19 15:30:17 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.007 Report Generated: 2016-05-19 15:29:35 2013 Residential Compliance Schema Version: 2013.1.007 CERTIFICATE OF VERIFICATION CF311-1VICH-20-1-1 Duct Leakage Diagnostic Test (Page 2 of 3 ) B. Duct Leakage Diagnostic Test 12 Notes C. Additional Requirements for Compliance 01 System was tested in its normal operation condition. No temporary taping allowed. Outside air (OA) duct connections to the central forced air duct system shall not be sealed/taped off during duct leakage testing. OA ducts used for Central Fan Integrated (CFI) Indoor Air Quality ventilation systems, or Central Fan Ventilation 02 Cooling Systems, that utilize dampers that open only when OA is required and automatically close when OA is not required, may configure the OA damper to the closed position during duct leakage testing. 03 All supply and return register boots were sealed to the drywall. 04 Building cavities were not used as plenums or platform returns in lieu of ducts. 05 If cloth backed tape was used it was covered with Mastic and draw bands. 06 All connection points between the air handler and the supply and return plenums are completely sealed. Visual Inspection at Final Construction Stage (applicable if system was tested at rough -in) After installing the interior finishing wall and verifying that the above rough -in tests was completed, the following procedure must be performed For all supply and return registers, verify that the spaces between the register boot and the interior finishing wall are 07 properly sealed. If the house rough -in duct leakage test was conducted without an air handler installed, inspect the connection points 08 between the air handler and the supply and return plenums to verify that the connection points are properly sealed. 09 Inspect all joints to ensure that no cloth backed rubber adhesive duct tape is used. 10 Verification Status Pass 11 Correction Notes for this table The responsible persons signature on this compliance document affirms that all applicable requirements in this table have been met unless otherwise noted in the Verification Status and the Corrections Notes in this table. D. Determination of HERS Verification Compliance All applicable sections of this document shall indicate compliance with the specified verification protocol requirements in order for this Certificate of Verification as a whole to be determined to be in compliance. 01 Complies: All specified verification protocol requirements on this document are met. Registration Number: 216-A0187750A-M2000001A-M20A Registration Date/Time: 2016-05-19 15:30:17 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.007 Report Generated: 2016-05-19 15:29:35 2013 Residential Compliance Schema Version: 2013.1.007 CERTIFICATE OF VERIFICATION CF3R-MCH-20-H Duct Leakage Diagnostic Test (Page 3 of 3 Documentation Author's Declaration Statement 1. 1 certify that this Certificate of Verification documentation is accurate and complete. Documentation Author Name: Documentation Author Signature: �+ on,5 Long Le oC -C, Company: Date Signed: LOTUS AIR CARE 2016-05-19 15:29:52 Address: CEA/ HERS Certification Identification (if applicable): 909 EAST HOMESTEAD ROAD City/State/Zip: Phone: SUNNYVALE CA 94087 408-892-6537 Responsible Person's Declaration statement I certify the following under penalty of perjury, under the laws of the State of California: 1. The information provided on this Certificate of Verification is true and correct. 2. 1 am the certified HERS Rater who performed the verification identified and reported on this Certificate of Verification (responsible rater). 3. The installed features, materials, components, manufactured devices, or system performance diagnostic results that require HERS verification identified on this Certificate of Verification comply with the applicable requirements in Reference Appendices RA2, RA3, and the requirements specified on the Certificate of Compliance for the building approved by the enforcement agency. 4. The information reported on applicable sections of the Certificate(s) of Installation (CF2R) signed and submitted by the person(s) responsible for the construction or installation conforms to the requirements specified on the Certificate(s) of Compliance (CF1R) approved by the enforcement agency. 5. 1 will ensure that a registered copy of this Certificate of Verification shall be posted, or made available with the building permit(s) issued for the building, and made available to the enforcement agency for all applicable inspections. I understand that a registered copy of this Certificate of Verification is required to be included with the documentation the builder provides to the building owner at occupancy. Builder Or Installer Information As Shown On The Certificate Of Installation Company Name (Installing Subcontractor, General Contractor, or Builder/Owner): Responsible Builder or Installer Name: CSLB License: HERS Provider Data Registry Information Sample Group Number (if applicable): Dwelling Test Status in Sample Group (if applicable) Tested HERS Rater Information HERS Rater Company Name: Builders' Energy Services, Inc. Responsible Rater Name: Responsible Rater Signature: Darrel Kelly Responsible Rater Certification Number w/ this HERS Provider: -B//JJ-S/- Date Signed: �i2l�L�(//�!%GG� CC2005655 OO 2016-05-19 15:30:17 Digitally signed by CaICERTS. This digital signature is provided in order to secure the content of this registered document, and in noway implies Registration Provider responsibility for the accuracy of the information. Registration Number: 216-A0187750A-M2000001A-M20A Registration Date/Time: 2016-05-19 15:30:17 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.007 Report Generated: 2016-05-19 15:29:35 2013 Residential Compliance Schema Version: 2013.1.007 4700 W. 160th St. /jam 0 Cleveland, OH 44135 PVC SHOWER PAN LINER ` PH:800-321-9532` FX:800-321-9535 IS0 900 www.oatey.com TECHNICAL SPECIFICATION TECHNICAL SPECIFICATION: Oatey PVC Shower Pan Liner is designed as an economical, flexible pan liner for use in tile shower and other concealed water -proofing applications. PVC Shower Pan Liner is available in 30 mil or 40 mil thickness, and widths of 4', 5' or 6'. Liner is marked every 6" to allow for easy measuring of material. 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