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11070006
CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20203 CAMARDA CT I CONTRACTOR: BILL GORMAN I PERMIT NO: 11070006 I OWNER'S NAME: BILL GORMAN 120203 CAMARDA CT I DATE ISSUED: 09/15/2011 I FR'S PHONE: 4084971100 11 License Class Contractor CUPE,RTINO, CA 95014 PHONE NO: LICENSED CONTRACTOR'S DECLARATION I BUILDING PERMIT INFO: BLDG F ELECT F PLUMB 1.. Lic. #_ I F MECH RESIDENTIAL COMMERCIAL' Date 1 hereby affirm that 1 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. 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 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. APPLICANT CERTIFICATION I certify that 1 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 9.1& Signature Date OWNER -BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 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) 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: 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. 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 ng of tht permit. Additionally, the applicant understands and will comply II non- pint sours regulations per the Cupertino Municipal Code, Secti,xi �JSignatury/ Date 1 JOB DESCRIPTION: ADDITION OF 831 SQFT,2 BEDROOMS, BATHROOM, FAM ILY ROOM & REMODEL OF KITCHEN, ENLARGE GARAGE TO TWO(2)CAR GARAGE & RELOCATE FURNACE & WATER Sq. Ft Floor Area: Valuation: $100000 APN Number: 31624024.20203 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. - 7 Issued by: -,- a Date:,.' _/57Z._ RE -ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, 1 agree to remove all new materials for inspection. Signature of Applicant- Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should 1 store or handle hazardous material. Additionally, should 1 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. O er or a a en[: Date: CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of vork's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Address A.RCH11 EC f'S IIECLARAI ION I understand my plans shall be used as public records. Licensed Professiona I CITY Or CUPERTINO BUILDING PERMIT I BUILDING ADDRESS: 10145 CAMINO VISTA DR OWNER'S NAME: SANJOY & SADIA PODDAR 'NER'S PHONE: 4083153523 VJ LICENSED CONTRACTOR'S D'E7CL,AJRATION License Class I—� Lie. # j/ _I Contractor D i�AM NAS I G,F-600J-.Date ` 2- I -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 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. FV ( APPLICANT CERTIFICATION V 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 OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 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) 1, 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: 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. 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, and expenses which may accrue against said City in consequence of the .ging 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 CONTRACTOR: DREAM CASTLE PERMIT NO: 11090019 CONSTRUCTION 4436 ROSCOMMON WAY DATE ISSUED: 09/02/2011 DUBLIN, CA 94568 PHONE NO: (408)898-0113 JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIALE] TEMP POWER POLE Sq. Ft Floor Area: I Valuation: $750 APN Number: 34214083.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 S OF PERMIT ISSUANCE OR 180 DA ROM L ST CALLED INSPE TI . Issued by: - Date: 2 �/ 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 of Applicant: Date: 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%3,, and 25534. Owner or authorized agent:(Date 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. Licensed Professional CITY OF CUPERTINO RK"M FEF. ESTIMATOR—111111,14INr nl1VIgI"N APPLIANCE / EQUIP TYPE ADDRESS: DATE: 09/02/2011 REVIEWED BY: UNITS APN: BP#: 'VALUATION: $750 -, 'PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Addition /Repair PRIMARY SFD or Duplex USE: Amps PENTAMATION 1 REAP14 PERMIT TYPE: WORK temp power pole SCOPE APPLIANCE / EQUIP TYPE FEE ID QTY/FEE QTY UNITS BP FEES Temporary Power 1 ERT<200 100 Amps $44 PME Unit Fee: $44.00 PME Permit Fee: $44.00 Work Without Permit? 0 Yes G No $0.00 TOTALS: i 1 $44.00 Strony, Motion Fee: 1BSEISMICR Elec. Plan Check 10.0 1 hrs $0.00 Elec. Permit Fee: IEPERMIT Other Elec. Insp. 1 0.0 1 hrs 1 $44.00 N%)TF._' ThPXP %PPQ //r0 havod /lit 1ho FEE ITEMS (Fee Resolution. 11-053 I . 'x'1.11) FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $44.00 PME Permit Fee: $44.00 Work Without Permit? 0 Yes G No $0.00 i Travel Documentation Fee: ITRAVDOC $44.00 Strony, Motion Fee: 1BSEISMICR $0.50 =hrs Admin./Clerical Fee $41.00 ]ADMIN Bid r Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $133.50 $41.00 TOTAL FEE: $174.50 Revised: 07/04/2011 CUPERTINO CONTRACTOR / SUBCONTRACTOR LIST Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 Fax: 408-777-3333 JOB ADDRESS: (� �' C� 1?` SUBCONTRACTOR PERMIT # OWNER'S NAME: PHONE # "9f �/ GENERAL CONTRACTOR: DR- w-1 ;' 77, c, ,' �WU6? BUSINESS LICENSE # ADDRESS: CITY/ZIPCODE: *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Signature Please check applicable subcontractors and complete the following information: q- z /l Date Owner / Contractor Signature 9'- z - i�/ Date SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring / Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner / Contractor Signature 9'- z - i�/ Date CUPERTINO GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 (408) 777-3228 - FAX (408) 777-3333 - buildina(dCUDertino.org ❑ PLUMBING ❑ MECHANICAL P111CTRICAL MEP MISC t ► Gg ❑ MISCELLANEOUS PROJECT ADDRESS I O (-' C k I / j© V l � r CUP P�� * S C 2- OWNER NAMESAtJ v 0 Y FO -DOA D PHONE Zfflg_ 5 5- 3 i 23 E M4II STREET ADDRESS 1 �' `� C4 ),L ( N( -'D V W � CITY, STATE, ZIP �O� CONTACT NAME PHONE E-MAIL STREET ADDRESS CITY, STATE, ZIP FAX ❑ OWNER ❑ OWNER -BUILDER ❑ OWNERAGENT ❑ CONTRACTOR CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME p �L CEN E NUMB Z� TLICENSE TYPE BUS. LIC # 72- COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARCHTTECTIENGINEER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME ' E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE 15E OF or DUPLEX C1MULTI-FAMII Y BUILDING: ❑ COMMERCIAL PROJECT IN WII DLAND El YES URBAN INTERFACE AREA ❑ NO PROJECT IN ❑ YES FLOOD ZONE ❑ NO IS THE BLDG AN ❑ YES EICHLER HOME? ❑ NO DESCRIPTION OF WORK p� p /J p Po.W1--- ?0 TOTAL VALUATION:���+ — RECEIVED BY: 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 relating to buil cons ."I orize representatives of Cupertino to enter the above -identified property for inspection puiposes. Signature of Applicant/Agent: Date: 1.— Z _ le SUPPLEMENTAL INFORMA7 REQUIRED OFFICE USE ONLY c :G U U OVER-THE-COUNTER ❑ EXPRESS ❑ STANDARD ❑ LARGE ❑ MAJOR AEPMisc 1pp_2011.doc revised 06121/11 CITY 07 CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20203 CAMARDA CT CONTRACTOR: BILL GORMAN PERMIT NO: 11070006 OWNER'S NAME: BILL GORMAN 20203 CAMARDA CT DATE ISSUED: 09/15/2011 OWNER'S PHONE: 4084971100 CUPERTINO, CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG I— ELECT r— PLIrIe0 ' License Class Lic.# Contractor 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 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. 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 OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 1, 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) 1, 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: 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 W'orker'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. 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 t i permit. Additionally, the applicant understands and will comply with all non- oint sourc regulations per the Cupertino Municipal Code, Section 9.18. Signatur Date M ECH RESIDENTIAL IT_ COMMERCIAL r— .DOB DIESCRIIPTION: ADDITION OF 831SQFT;2 BEDROOMS,BATHROOM,FAMILY ROOM & REMODEL OF KITCHEN, ENLARGE GARAGE TO TWO(2)CAR GARAGE & RELOCATE FURNACE & WATER Sq. Ft Floor Area: Valuation: $100000 APN Number: 31624024.20203 Occupancy Type: PERMIT ]EXPIRES IF WORK IS NOT STARTED WIT H ffN 180 DAYS OF P ERMffT ffSSUA C E OR 180 DAYS FROM ]LAS'S' CALLED INSPECTION. Issued by: ��.C7.r---�„� r_pDate:,�—�� RE -ROOFS: All roofs shall be inspected prior to any roofing material being installed. if a roof is installed without first obtaining an inspection, l agree to remove all new materials for inspection. Signature of Applicant: Date: 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(x) 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 compliatree with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. O er or a a ent: Date: 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 Add ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT e BUILDIN .-n'ft �J�� o` _�f1A 10300 TORRE AVENUE ^ CUPERTINO, CA 95014-3255 (408) 777-3228 ^ FAX (408) 777-3333 ^ buildingecupertino.org ❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION I TI a REVISION I DEFERRED /10va� ORIGINAL PERMIT k Lam. PROJECT ADDRESS�'2'� O APN # OWNER NAME PHONE E-MAIL STREET ADDRESS CITY, STATE, ZIP gt2 202) FAX CONTACT NAME PHONE E-MAIL STREET ADDRESS CITY, STATE, ZIP FAX ❑ OWNER ❑ OWNER-BUILDFR _ ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSENUMBER, LICENSE TW BUS. LIC # COMPANYNAME FAX 6 STREET ADDRESS CITY, STATE, ZIP PHONE - e BUS. LIC # ARCHITECT/ENGTNEER NAME LICENSE NUMBER COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCR.IP71ON OF WORK V W EXISTING USE PROPOSED USE CONSTR. TYPE # STORIES USE TYPE OCC. SQ.FT. VALUATION (S) EXISTG NEW FLOOR DEMO AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH ❑ ATTACH #DWELL TS: UNIT ❑YES SECOND STORY [3YES 71SACOND ADDED? []NO ADDITION? []NO PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF PLANNING APPL # []NO PLANNING APPROVAL LETTER IS THE BLDG AN ❑ YES EICHLER HOME? []NO .RECEIVED B1' :_. r f : TOTAL VALUATION: By my signature below, I certify to each of the folloWi am the property owner or au rized agent to act on the property owner's behalf. I have read this application and the information I have provided is c t. I r d the De do ark and verify it is accurate. I agree to comply With all applicable local ordinances and state laws relating to buildings ction au rize re e of Cupertino to enter the above -identified property for inspection purposes. Signature of Applicant/Agent: Date: & -1-e /� SLiPPLE1v1ENTAL INFORMATION RE IRED PI,AN.CHECAa1,>?E 1'2, rvF r` r 0�1RTHE-COU t N ANREVIEW i New SFD or Multifamily dwellinos: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of buildings permit for new building. PLAINWNGPLAIVREVIEW- Hazardous Materials Disclosure -A ❑ t7 ❑ ruBLrc�ioRLs Commercial Bldgs: Provide a completed .srAND�RD �� _ form if any Hazardous Materials are being used as part of this project.c�3 t ❑ LARGE { � �, � ❑ `FIRE DEPT'' , Copy of Planning Approval Letter or Meeting with Planning prior toR ❑ t r i ❑ SANITARY SE11 ER DISRICT _ submittal of Building Permit application. MAJOR , . ' , r s, . x: a.:..n r❑i:.ENVII20. lENTALAEALTH.+ ❑ NEW CONSTRUCTION C OO MSCI RUCTM PER N F APPUC A M COMMUNITY DEVELOPMENT DEPARTMENT ^ BUILDING DIVISION 10300 TORRE AVENUE ^ CUPERTINO, CA 95014-3255 (408) 777-3228 a FAX (408) 777-3333 o building -cuaertino.org //C)7 Doi �) Is ADDITION ❑ ALTERATION / TI ❑ REVISION / DEFERRED ORIGINAL PERMIT # PROJECT ADDRESS 20203 f F)M X),p C� APN # ��� � Py / � s �� i� . yEMAIL OWNER NAME a)a1 �C®• �Od PHONE O® 8Yi"'0q&d ADA�M0 STREET ADDRESS 2 0 20-1 C,, �8,9pA Cy I CITY, STATE, ZIP C uG�TIevo, ce9 FAX CONTACT NAME �% PHONE "S�`�(/Pl EMAIL � r STREET ADDRESS 795 dd t1jli,� P,� CITY, STATE, ZIP, � � FAX ❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT 9ARCHrmcr ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTORN6ME MID LICENSE NUMBER LICENSE TYPE BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARCHITECTIENGTNEERNAME ^, FA 40 _ / LICENSENUMBER BUS. LIC# COMPANYNAME Ppofii 46�c /� / E-MAIL �0� �0.1v6��09AY n _!% o� FAX 641Y`ryIry / STREET ADDRESS �!� ' CITE STATE ZIP P 0 736' 09*Z DESCRIPTION OF WORK `rioAl 0 F &on . A01 -0m ® ou �Ct71 eA '.. EXISTING USE y� PROPOSED US�E�y ���� CONSTR. TYPE # STORIES OFFICE CSC -0--IL- NLY ''.... KC.6l i 1 L, � 1 OCC OCC. TYPE DESCRIPTION .FT ON 5 NEW R I DEMO TOTAL EXIST tp�a AREA AREAL�k3 / AREA NET AREA d J / y\ ✓ /VpAL / elk— BATHROOM �/ KITCHEN OTHER I 16 REMODEL AREA REMODEL AREA REMODELAREA PORCH AREA I DECK AREA TOTAL DECKIPORCH AREA I GARAGE AREA:,❑.,/DETACH Gy ATTACH q DWELLING UNITS: 2- IS A SECOND UNIT ❑ YES SECOND STORY ❑ YES i< BEINGADDED! 0146 ADDITION! PRE -APPLICATION [JfYES IF YES, PROVIDE COPY OF PLANNER' xANE: V(101V67– RECEIVED BY: TOTAL VALUATION: PLANNING APPL0 ❑ NO PLANNING APPROVAL LETMR 5IAJ EW By my signature below, I certify to each of the following: 1 am the prop owner or authorized agent to act on the property owner's behalf. 1 hav ead this application and the information 1 have o ided is corn t. 1 have read escr' n of Work and verify it is accura . 1 agree to comply with all applicable local ordinances and state laws relating to gons n, t z Cu i to enter th - -idIpnf IlpFperty for inspection purposes. Signature of Applicant/Agent: Date:' 1 SUPPLEMENTAL INFORMATION REQUIRED PAN CHECK TYPE ROUTING SLIP New SFD or Multifamily dwellings: Apply for demolition permit for --sua _ existing building(s). Demolition permit is required prior to issuance of building D �c PLAN REvtew permit for new building. ❑ E�PRS ��PLANNING PLAN REVIEW Bldgs: Provide a completed Hazardous Materials Disclosure STRD -E1 PUBLIC WORKS _Commercial To—nn if any Hazardous Materials are being used as part of this project. ❑ � �2E LARGE 1�,/ DEPT _ Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR ❑ SANITARY SEWER DISTRICT submittal of Building Permit application. ❑ ENVIRO\'MENTAL HEALTH BldgApp_201 Ldoe revised 03116111 07Y OF CUPERUNO �$ FEE I ESUMATOR L. I I I II► I\ G ID I I S 14► \ ADDRESS: 20203 camarda ct. DATE: 07/09/2099 1F1LR AREA s.f REVIEWED BY: bobs. PC ]FEE ID APN: 1BP#: Q (C/ II-B,III-B,NN-B *VALUATION: Iso *PERMITTYPE: Building Permit PLAN CHECK TYPE: Addition PRIMARY SFD or Duplex USE:OTC. 2nd Unit? Yes o No 0 Yes (DNo PENTAMATIION 1 R3SFDADD PERMIT IT TYPE• sfd add 2 bedrooms bathroom family room add to existing garage = 831 sq ft. Remodel kitchen= 167 LWORK SCOPE sq. ft. relocate water heater, and furnace. $0.00 OCCUPANCY TYPE: TYPE OF CONSTR. 1F1LR AREA s.f PC ]FEES PC ]FEE ID IBP ]FEES IBP 1F'EE IIIID R-3 (Custom) II-B,III-B,NN-B 831 $2,349.00 IR3PLNCK $1,474.00 IR3INSP ,iSC. /"� t'Cr: $0.00 Permit Fee: $1,474.00 Suppl. Insp. Fee:a Reg. 0 OT 0.0 firs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $42.00 t"rPrt::•E.rta�frcr<r Tir.t TOTALS: 831 $2,349.00 $0.00 $1,474.00 M1ECH, HOURLY 0 Yes ('No PLUMB, HOURLY ® Yes E) No EILEC, HOURLY 0 Yes Q No M1ISC ITEMS Plumb. Plan Check 0.0 hrs $0.00 ;`o... Plumb. Permit Fee: 1PPERMIT 167 s.f. Remodel, Kitchen (<=300 sf) $570.00 1REMRESKIT Other Plumb Insp. 0.0 7hrs L$42.00 11:, :. blvp. i1 l..�r<.. T% z(?. , ('.C." t'i�iaii?=� lr:. ��7. {.: •.'t'. ,iSC. /"� t'Cr: NOTE: These fees are based on the Dreliminary information available and are only an estimate. Contact the Dent for addn'l info. ]FEE I[T]EMS (Fee Resolution 09-051 P '. 7 1/l j) ]FEE QTY/FEE M1ISC ITEMS Plan Check Fee: $2,349.00 167 s.f. Remodel, Kitchen (<=300 sf) $570.00 1REMRESKIT Suppl. PC Fee: E) Reg. 0 OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $1,474.00 Suppl. Insp. Fee:a Reg. 0 OT 0.0 firs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $42.00 t"rPrt::•E.rta�frcr<r Tir.t Acoustical Fee: ® Yes G No $0.00 0 0 Work Without Permit? Q Yes 0 No $0.00 Planning Fee: PLLONGRNGR $108.03 Select a Non -Residential Building or Structure E) 0 Travel Documentation Fee: Strong .Motion Fee: $0.00 Select an Administrative Item Bldg Stds Commission F'ee: $0.00 SUBTOTALS: $4,015.03 $595.00 TOTAL FEE- $4,610.03 Revised: 04/29/2011 C-"J� 1 LUPfR ICj e,4q-1,n,44,&4 CONTRACTOR / S1 PO \11111:.7: Building IDepartment City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 Fax: 408-777-3333 JOB ADDRESS: PERMIT # vo � OWNER'S NAME: PHONE # GENERAL CONTRA OR: BUSINES LICENSE ADDRESS: j, CITY/ZIPCODE: _ *Our municipal code requires all buss nesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY I T PIECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCON ' CT IIA INED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Signature Date Pllease check applicable subcontractors and complete the ffollloawing information: V SUBCONTRACTOR BUMN ESS RAMIE BUSINESS LIICIENSIE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring / Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile 4wneir / C ntractor Signature Date CUPERTINO COMMUNITY DEVELOPMENT DEPARTMENT > BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 o FAX (408) 777-3333 - buildino(a)cupertino.ora 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 AD►DFgES J�A/ '" �� ((���di-7%P� A n� BP# / J`�i�� Ou OWN �ADDREStAm �gC/'QJ' Cr D' e f t y� '/-� DESCRIPTION O WORK: 1 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 ARID VERIFICATION OF INFORMATION (DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information.) 0-1. 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. � ,ins Trance coverage for injuries to workers on my property. !; '"2. 1 understand building permits are not required to be signed by property owners unless they are responsible for ;they nstruction and are not hiring a licensed Contractor to assume this responsibility. . I understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I -may protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her 04. teal of my own. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. V. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be con ' ered an "employer" under state and federal law. 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 tip serious financial risk. Y. 1 understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is Rrformed under contract with a licensed general building Contractor. '� V` 8. 1 understand'as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for any financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the workmanship or materials. OwnerBuilderFonn 2010.doc revised 04/14/10 9. 1 understand I may obtain more information regarding my obligations as an "employer" from the Internal Revenue Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed Jahe, ctors. 0. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I party legally and financially responsible for proposed construction activity at the site address listed above. 1. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide pplicable laws and requirements that govern Owner -Builders as well as employers. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If you contract with someone who does not have a license, the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or employee of that individual or firm is injured while working on your property, you 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 Iss ed, this form must be completed and signed by the property owner and returned to the agency responsibl ,for issui the permit. Note: A copy of the property owner's driver's license, form notarization, or other verificati n acceptab he ity may be required to be presented when the ermit is issued to verifythe roe owner's si n07 7 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 owner's signature. Property Owner's Signature: Date: O1v-nerBuilderForm 2010.doc revised 04114110 L> CMpEG°3TMO May 6, 2011 Pronovate, LLC Attn: Rachel Matalon 785 Harking Dr. Sunnyvale, Ca. 94087 OFFICE OF COMMUNITY DEVELOPMENT CITY HALL 10300 TORRE AVENUE a CUPERTINO, CA 95014-3255 (408) 777-3308 o FAX (408) 777-3333 o planningacupertino orq SUBJECT: DESIGN REVIEW COMMTIZ'EE ACTION LETTER - Application ASA -2011-07 This letter confirms the decision of the Design Review Committee, given at the meeting of May 5, 2011; approving an Architectural and Site approval for an addition to a residential duplex, located at 20203 Camarda Court, according to Resolution No. 305. Please be aware that if this permit is not used within two years, it shall expire on May 5, 2013. Also, please note that an appeal of this dee iot can be made Withift 14 ealendm dais ftbm the mailing of the notification of this decision. If this happens, you will be notified of a public hearing, which will be scheduled before the City Council. Sincerely, Q -- Simon Vuong Assistant Planner City of Cupertino Ehelogures: Resolution No. 305 CC: Bill Gorman, 20199 CatlWda Ct, Cupertino CA 95014 David Kopels,10161 Bilich Pl, Cupertino CA 95014 Daniel O'Keefe, 34 Paseo Alba, San Clemente CA 92672 ASA -2011-07 CITY OF CUPERTINO 10300 Torre Avenue Cupertino, California 95014 RESOLUTION NO: 305 OF THE DESIGN REVIEW COMMITTEE OF THE CITY OF CUPERTINO APPROVING__ ARCHITECTURAL AND SITE REVIEW FOR AN ADDITION TO A RESIDENTIAL DUPLEX LOCATED AT 20203 CAMARDA COURT SECTION 1: FINDINGS WHEREAS; the Design Review Committee of the City of Cupertino received an application for an Architectural and Site Approval as described in Section H of this Resolution; and WHEREAS, the necessary public notices have been given in accordance with the Proeedural Ordit=ce of the City of Cupertino, and the Design Review Committee has held one or more public hearings on this matter; and WHEREAS, the applicant has suet the burden of proof required to support said application; and has satisfied the following requirements: 1. The proposal will not be detrimental or injurious to property or improvements in the vicinity, and will not be detrimental to the public health, safety, general welfare, or convenience; 2. The proposal is consistent with the purposes of this chapter, the General Plan, any specific plan, zoning ordinances, applicable use permits, variances, subdivision maps or other entitlements to use which regulate the subject property including, but not limited to, adherence to the following__ specific criteria: a) Abrupt changes in building scale is avoided and a gradual transition related to height and bulk is achieved; b) The materials, textures, and colors of new buildings or additions harmonize with adjacent development by being consistent or compatible with design and color schemes, and with the future character of the neighborhood and purposes of the R-2 zone. NOW, THEREFORE, BE IT RESOLVED: That after careful consideration of claps, facts, exhibits, testimony and other evidence submitted in this shatter, the application for Architectural Site Approval is hereby approved, subject to the conditions which are enumerated in this Resolution beginning on page 2 thaeo€; and That the subconclusions upon which the findings and conditions specified in this resolution are based and contained in the public hearing record concerning Application ASA -2011-07 set forth in the Minutes of the Design Review Committee meeting of May 5, 2011 and are incorporated by reference as though fully set forth herein. SECTION 11: PROTECT DESCRIPTION Application No.: ASA -2011-07 Applicant: Rachel Matalon Property Owner: Bill Gorman Location: 20199 & 20203 Camarda Court Resolution No. 305 ASA -2011-07 May 5, 2011 Page 3 fail to file a protest within this 90 -day period complying with all of the requirements of Section 66020, you will be legally barred from later challenging such exactions. PASSED AND ADOPTED this day of May 5, 2011, at a Regular Meeting of the Design Review Committee of the City of Cupertino, State of California, by the following roll call vote: AYES'. COMMITTEE MEMBERS: Chair Miller, Brownley NOES: COMMITTEE MEMBERS: none ABSTAIN: COMMITTEE MEMBERS: none ABSENT: COMMITTEE MEMBERS: Sun ATTEST: APPROVED! /s/Gary Chao Gary Chao City Planner & \ Plahii iig \ DRC � Y6d1 ltioM \2011 \ ASA -2011-07 res.doc /s/Marty Miller Marty Miller, Chair Design Review Committee ENSTALILAT><ON CIERTI FE(CAT E (Page ll OT Il 2) CIF -6R Si a Address ,O,;*70.3 &F Permit Number In Ilation certificates (CF6R)are required for each and every dwelling unit. When the installation of measures that require field verification and diagnostic testing is complete, the builder or the builder's subcontractor shall complete diagnostic testing and the procedures specified in this section. When the installation is complete, the builder or the builder's subcontractor shall complete the CF -6R (Installation Certificate), and keep it at the building site for review by the building department. The builder also shall provide a copy of the Installation Certificate to the HERS rater for any measures requiring field verification and diagnostic testing, per Section 10-103(a). WATER HEATfNG SYSTEMS: Distribution CEC Certified Type Heater Mfr Name & (Std, Point- Type Model Numbe of-vsea4j, If # of Rated Input External Recirculation, Identical (kW or Tank Volume Efficiency Standby Insulation Control Type Systems Btu/hr)t(gallons) (EF, RE)2 Loss %)2 R-value2 60 k 2 1 For small gas storage (rated input of less than or equal to 75,000 Btu/hr), electric resistance and heat pump water heaters, list Energy Factor (EF). For large gas storage water heaters (rated input of greater than 75,000 Btu/hr), list Recovery (RE), Thermal Efficiency, Standby Loss and Rated Input. For instantaneous gas water heaters, list Thermal Efficiency and Rated Input. 2. R-12 external insulation is mandatory for storage water heaters with an energy factor of less than 0.58. Kitchen piping: If indicated on the CF -1R, all hot water piping >_ 3/4 inches in diameter that runs from the hot water source to the kitchen fixtures is insulated. 1 rL- All ]Faucets & Shower Heads: faucets and showerheads installed are certified to the Energy Commission, pursuant to Title 24, Part 6, Section 111. Central Water Heating in Buildings with Multiple Dwelling Units (required for prescriptive) J ®All hot water piping in main circulating loop is insulated to requirements of §1500) ®Central hot water systems serving six or fewer dwelling units which have (l) less than 25' of distribution piping outdoors; (2) zero distribution piping underground; (3) no recirculation pump; and (4) insulation 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 control or a time/temperature control el, the undersigned, verify that equipment listed above my signature is: 1) 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 R Owner Signature Date: Copies to: BUILDING DEPARTMENT, HERS RATER (IF APPLICABLE) BUILDING OWNER AT OCCUPANCY Residential Compliance Forms September 2005 M7AILILATIGN C EIEB71RCA7 E ,� (Page 2 of Ili) CIF -6R Site Address ..��3 Permit Number ,e�2® An,itfstallitron certificate is reauired to be nosted at the building site or made available for all annronriate insnections- (The information provided on this form is required) After completion of final inspection, a copy must be provided to the building department (upon request) and the building owner at occupancy, per Section 10-103(a). ]F]EN EMAUON/G LAZING: '� Use values from a fenestration product's NFRC label. For fenestration products without an NFRC label, use the default values from Section 116 of the Energy Efficiency Standards. 2) Installed U -factor must be less than or equal to values from CF -1R. Installed SHGC must be less than or equal to values from CF -1R, or a shading device (exterior or overhang) is installed as specified on the CF -1 R. Alternatively, installed weighted average U -factors for the total fenestration area are less than or equal to values from CF -1R. If using default table SHGC values from §116 identify whether tinted or not. EY I, the undersigned, verify that the fenestration/glazing listed above my signature: 1) is the actual fenestration product installed; 2) is equivalent to or has a lower U -factor and lower SHGC than that specified in the certificate of compliance (Form CF -1R) submitted for compliance with the Energy Efficiency Standards for residential buildings; and 3) the product meets or exceeds the appropriate requirements for manufactured devices (from Part 6), where applicable. Item #s (if applicable) Manufacturer/Brand • RODUFTS) CF- I R value) Product SHGC 2 (5CF-Mvalue) Total Quantity Like Product (Qpliona� Square CommentsifLocation/ Feet Special Features Installing Subcontractor (Co. Name) OR (if applicable) General Contractor (Co. Name) OR Owner !"yr�ri/0 /l�J1/jam, �I OR Window Distributor Item #s Signature Installing Subcontractor (Co. Name) OR (if applicable) General Contractor (Co. Name) OR Owner ® --_--- o, WE --_--- '� Use values from a fenestration product's NFRC label. For fenestration products without an NFRC label, use the default values from Section 116 of the Energy Efficiency Standards. 2) Installed U -factor must be less than or equal to values from CF -1R. Installed SHGC must be less than or equal to values from CF -1R, or a shading device (exterior or overhang) is installed as specified on the CF -1 R. Alternatively, installed weighted average U -factors for the total fenestration area are less than or equal to values from CF -1R. If using default table SHGC values from §116 identify whether tinted or not. EY I, the undersigned, verify that the fenestration/glazing listed above my signature: 1) is the actual fenestration product installed; 2) is equivalent to or has a lower U -factor and lower SHGC than that specified in the certificate of compliance (Form CF -1R) submitted for compliance with the Energy Efficiency Standards for residential buildings; and 3) the product meets or exceeds the appropriate requirements for manufactured devices (from Part 6), where applicable. Item #s (if applicable) Signature Date Installing Subcontractor (Co. Name) OR General Contractor (Co. Name) OR Owner OR Window Distributor Item #s Signature Date Installing Subcontractor (Co. Name) OR (if applicable) General Contractor (Co. Name) OR Owner OR Window Distributor Item #s Signature Installing Subcontractor (Co. Name) OR (if applicable) General Contractor (Co. Name) OR Owner OR Window Distributor o, Copies to: ]Building Department, HERS Rater (if appfleabge) ]Buh0ding Owner at Occupancy Residential Compliance Forms April 2005 N go INSTALLATION CIEI[8' URCAT E (Pzge 3 oT n) (CIF -6R Site Address zld's-��911 r Permit Number 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 must be provided to the building department (upon request) and the building owner at occupancy, per Section 10-103(a). HVAC SYSTEMS: ]Beating Equipment Equip Type (pkg. heal um CEC Certified Mfr. Name and Model Number # of Identical Systems Efficiency� (AFUE, etc.) zCF-1R value) Duct Location attic et . Duct or Piping R -value Heating Load Heating Capacity Btu/hr D �— jBBtpu//hr 1�[l�"J l�- 6% AJ l Cooling Equipment Equip Type k .heat um CEC Certified Mfr. Name and Model Number # of Identical 5 stems>_CF-1R Efficiencyt (SEER or EER) value) Duct Location attic etc. Duct R -value Cooling Load Btuthr Cooling Capacity Btu/Iv 1. > symbol reads greater than or equal to what is indicated on the CF- I R value. Include both SEER and EER if compliance credit for high EER air conditioner is claimed. dl, 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 -IR) 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 Subcontr for (Co. Name) OR G eral Contractor (Co. e) O caner ' Signature: Date: _ Copies to: BUILDING (DEPARTMENT, HERS RATER (IF APPLICABLE) ]BUIL®IINO OWNER AT OCCUPANCY Residential Compliance Forms April 2005 INSTAILILA' IDN C]ERTIFdCAT E /I page 4 aT n) COIF -6R Site dressZ4V ,p 3 Permit Number HWTALLER COMM,lIANCIE STATEMENT FOR DUCT LEAKAGE IINSTALLIEIR COMPLIANCE STATEMENT The building was: V'J ®Tested at Final Tested at Rough -in ALLER VISUAL INSPECTION AT FINAL CONSTRUCTION STAGE FOR MEbff DUCTS: Remove at least one supply and one return register, and verify that the spaces between the register boot and the interior finishing wall are properly sealed. ❑ 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. Inspect all joints to ensure that no cloth backed rubber adhesive duct tape is used on new ducts. J ❑ DUCT LEAKAGE REDUCTION Procedures for field verification and diagnostic testine of air distribution smievm are available in RA CM. A®nendix RC9.3 NEW CONSTRUCTION: Duct Pressurization Test Results (CFM @ 25 Pa) Measured Values Signatu 1 Enter Tested Leakage Flow in CFM: _ Fan Flow: Calculated (Nominal: V ❑ Cooling V Heating) or V ❑ Measured 2 If Fan Flow is Calculated as 400 cfm/ton x number of tons or as 21.7 cf V(kBtu/hr) x Heating e Capacity in Thousands of Btu/hr, enter total calculated or measured fan flow in CFM here: ,"� 2 V ai d d 3 Pass if Leakage Percentage < 6% for Final or < 4% at Rough -in without air handle: a 79 pass ❑Fail 100 x ine # 1 / Line # 2 ALTERATIONS: Duct System and/or HVAC ]Equipment Change -Out Enter Tested Leakage Flow in CFM from ]Pre -Test of Existing Duct System Prior to Duct _ 4 System Alteration and/or Equipment Change -Out. Enter Tested Leakage Flow in CFM from Final Test of New Duct System or Altered Duct 5 System for Duct System Alteration and/or Equipment Chan e -Out. Enter Reduction in Leakage for Altered Duct System 6 Line # 4 Minus Line # 5 —(Only if Applicable) 7 Enter Tested Leakage Flow in CFM to Outside (Only if Applicable) d d Entire New Duct System - Pass if Leakage Percentage < 6% for Final. ❑pass ❑Fail 8 100 x Line # 5 / Line # 2 TEST OR VERIFICATION STANDARDS: For Altered Duct System and/or HVAC ]Equipment Change- d d Out Use one of the following four Test or Verification Standards Tor compliance: 9 Pass if Leakage Percentage < 15% [100 x [ (Line # 5) / (Line # 2)11 ❑ Pass ❑ Fail 10 Pass if Leakage to Outside Percentage < 10% [100 x (Line # 7) / (Line # 2)1] ❑ Pass ❑ Fail Pass if Leakage Reduction Percentage > 60% [100 x L—(Line # 6) / (Line # 4)11 ❑ Pass ❑ Fail 11 and Verification by Smoke Test and Visual Inspection 12 Pass if Sealing of all Accessible Leaks and Verification by Smoke Test and Visual Inspection ❑ Pass ❑ Fail Pass if One of Lines # 9 through # 12 pass ❑ Pass ❑ Fail d ® I, the undersigned, verify that the above diagnostic test results were performed in conformance with the requirements for compliance credit. I, the undersigned, also certify that the newly installed or retrofit Air -Distribution System Ducts, Plenums and Fans comply with Mandatory requirements specified in Section 150 (m) of the 2005 Building Energy Efficiency standards. Installing Subco cto o. Name) OR G era] Co ctor (Co. Name) OR Owner Signatu Date: 6 , lov, - Copies to: BUILDDING IDEPAIR'Il'li9ENIl', HEIRS RATER (IE APPLICABLE) BUILDING OWNER AT OCCUPANCY Residential Compliance Forms December 2005 INSTALLATION CERTIFICATE gage s ofi n) CIF -6R Site Address _ Permit Number IJ TIEI(]ERMOSTA T11C IEX PANSQON VALVE (TR{V) Procedures for field verification of thermostatic expansion valves are available in RACM, Appendix RI. d � Access is provided for inspection. The procedure shall C consist of visual verification that the TXV is installed on Return (evaporator entering) air dry-bulb temperature (Treturn, db) Yes ❑ No the system and installation of the specific equipment 21 ro shall be verified. Yes is a pass Pass I Fail V'M R1ElF1RJG1ERANT (CHARGE MEASUREMENT Verification for Required Refrigerant Charge and Adequate Airflow for Split System Space Cooling Systems without Thermostatic Expansion Valves Outdoor Unit Serial # C Location Return (evaporator entering) air dry-bulb temperature (Treturn, db) Outdoor Unit Make OF Outdoor Unit Model Cooling Capacity Evaporator saturation temperature (Tevaporator, sat) Stu/hr Date of Verification Suction line temperature (Tsuction, db) Date of Refrigerant Gauge Calibration F (must be checked monthly) Date of Thermocouple Calibration °F (must be checked monthly) Sitandaird Chairpe Measurement IPirocedauu a (outdoor air dry-bulb 55°F and above): Procedures for Determining Refrigerant Charge using the Standard Method are available in RACM, Appendix RD2. Note: The system should be installed and charged in accordance with the manufacturer's specifications before starting this procedure. Measured Temperatures Supply (evaporator leaving) air dry-bulb temperature (Tsupply, db) C OF Return (evaporator entering) air dry-bulb temperature (Treturn, db) OF Return (evaporator entering) air wet -bulb temperature (Tretum, wb) OF Evaporator saturation temperature (Tevaporator, sat) OF Suction line temperature (Tsuction, db) °F Condenser (entering) air dry-bulb temperature (Tcondenser, db) °F Sunerheat Charge Method Calculations for Refrigerant Charge Actual Superheat = Tsuction, db — Tevaporator, sat C OF Target Superheat (from Table RD -2) OF Actual Superheat — Target Superheat (System passes if between -5 and +5°F) OF Temperature Split Method Calculations for Adequate Airflow Split Method Calculation is not necessary ifAdequate Airflow credit is taken Actual Temperature Split = T return, db Tsupply, db C OF Target Temperature Split (from Table RD3) °F Actual Temperature Split Target Temperature Split (System passes if between - 3°F and +3°F or, upon remeasurement, if between -3°F and -100°F °F Residential Compliance Forms April 2005 1[1` iTAILILA7ECO Y C ElE 71FRCATZ (Page 6 aT 12) CIF -6R - Site A 'dress Permit Number Standard Charge Measurement Summary: System shall pass both refrigerant charge and adequate airflow calculation criteria from the same measurements. If corrective actions were taken, both criteria must be remeasured and recalculated. ❑ Yes 1 ❑ No I System Passes AI«ernatte Charge Measurement Piroeeduire (outdoor air dry-bulb below 55 °F) Note: The system should be installed and charged in accordance with the manufacturer's specifications and installer verification shall be documented on CF -6R before starting this procedure. If outdoor air dry-bulb is 55 of or above, installer shall use the Standard Charge Measure Procedure: Procedures for Determining Refrigerant Charge using the Alternate Method are available in RACM Appendix RD3. Weigh -[n Charging Method for Refrigerant Charge Actual liquid line length: ft Manufacturer's Standard liquid line length: O ft Difference (Actual — Standard): ft Manufacturer's correction (ounces per foot) x difference in length = ounces (+ = add) (- = remove) 4easured Airflow Method for Adequate Airflow Verification available in RACM, Appendix RD2.6 Calculated Airflow: Cooling Capacity (Btu/hr) X 0.033 (cfm/Btu-hr) = CFM Measured Airflow is CFM (Measured airflow must be greater than the calculated airflow). Alternate Charge Measurement Summary: System shall pass both refrigerant charge and adequate airflow calculation criteria from the same measurements. If corrective actions were taken, both criteria must be remeasured and recalculated. ❑ Yes 113 No I System Passes Installing Subcontractor (Co. Name) OR General Contractor (Co. N OR >tyr Signator . Date: Copies to: BUILDING DEPARTMENT, REBS RATER (IF APPLICABLE) BUILDING OWNER AT OCCUPANCY Residential Compliance Forms April 2005 IQ%TAILILA')ITI ON CIEIlBTE FRCA>T'IE (Jhg¢ i oT 12) (CIF -6R Site Address Permit Number NS (CRIEIIDIITS J IN DIAGNOSTIC SUPPLY DUCT LOCATION, SURFACE AREA AND R -VALUE Proceiduyeforfield verification and diagnostic testing for this group compliance credits are available in RACH, Appendix RC, RE & RH. LESS THAN 12 LINEAL FEET OF SUPPLY DUCT OUTSIDE OF CONDIITiIONED SPACE CQJ4PLIANCE CREDIT J es I []No I Less than 12 lineal feet of supply duct outside of conditioned space. Yes to this compliance credit is a pass JUrPass ❑ Fail Rb 6PLY DUCTS iLOCATED IN CONDiITIIONED SPACE COMPILIIANCE CREDIT lI� Yes I ❑ No I Ducts are located within the conditioned volume of building. Yes to this compliance credit is a pass Ur Pass 1 ❑ Fail Duct System Design verification is required for a compliance credit for the ToHowing: 1. Supply duct surface area reduction 2. ]Buried supply ducts on the ceiling 3. Deeply buried supply ducts ® DUCT SYSTEM DESMON VERIFICATION HISUPPLY DUCTS SURFACE AREA REDUCTIION COMPLIANCE CREDIT Crawl Attic Space Basement R"Yes ❑ No Adequate airflow verified �1es R-4.2 Surface Area ❑ No The duct system design plan meets the requirements specified in RACM, Appendix RE, Section RE.4.2 7 &Yes ❑ No The duct system design plan exists on building plans �1 Yes ❑ No Duct sizes, duct system layout and locations of supply & return registers match the duct system design plan Yes to all is a pass v' ❑ Pass ❑ Fail HISUPPLY DUCTS SURFACE AREA REDUCTIION COMPLIANCE CREDIT Crawl Attic Space Basement Covered Deeply Covered Other Duct Diameter R-4.2 Surface Area R-6.0 Surface Area R-8.0 Surface Area ❑ ❑ 11 ❑ %yii 50 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Total Surface Area for Each R -Value Yes I ❑ No ktches Performance's CF -1R? Yes to all is a pass Pass ❑ Fail c/ rl 1R1f TT�r1R1(D 1(D1f TR"" lf'S �DI�Y 'lf'1FTIIF t<"'1F.1f1f ,IfI�iQT' CQUIyiIIPIf .IIAl�1CIF. �'1181F,DI'If' ❑ Yes ❑ No Buried Ducts on the Ceiling ❑ Yes ❑ No Verified High Insulation Installation Quality V Yes to duct system design, supply duct surface area reduction and this compliance credit is a pass ❑ Pass ❑ Fail ,1 171iiDTF.1F.TPD V TRRIIRTTTFD TbOir7,q CtDhYii1PI.IANrIF. CRF.Dff7 J ❑ Yes ❑ No Deeply Buried Ducts * ❑ Yes ❑ No Verified High Insulation Installation Quality J J 1 Yes to ducts stem design, supply duct surface area reduction and this compliance credit is a pass ❑Pass ❑ Fail Copies to: BUILDING DEPARTMENT, HERS RATER (IIF APPLICABLE) BUILDING OWNER AT OCCUPANCY Residential Compliance Forms April 2005 I(P STAILILATION OIEI[8'I< URCAT E , , (IPzge a oft n) CIF -(&R Site Addresses �� 7 _ Permit Number d LT FAN WATT DRAW Procedures for measuring the air handler watt draw are available in RACM. Annendix RF.3.2. Method For Fan Watt Draw Measurement J ❑ RE3.2.1 Portable Watt Meter Measurement RE3.2.2 Utility Revenue Meter Measurement Adequate airflow verified (see adequate airflow credit) Refrigerant charge or TXV Measured Fan Watt Draw J Measured Fan Flow enter total cfin from airflow verification d � Enter results of Watts/cfm� J ❑ Yes ❑ No 0"Yes ❑ No Measured fan watt/cfm draw is equal to or lower than the fan watt/cfm draw documented in CF -1R ❑ Yes ❑ No 5 J Yes is a pass I Pass Fail �!Rr ADEQUATE AIRFLOW VERIFICATION Procedures or measuring the airflow are available in RACM, Appendix RE3.1. Method For Airflow Measurement ❑ RE4.1.1 Diagnostic Fan Flow Using Flow Capture Hood ❑ RE4.1.2 Diagnostic Fan Flow Using Plenum Pressure Matching RE4.1.3 Diagnostic Fan Flow Using Flow Grid Measurement Yes ❑ No Duct design exists on plans Watts cfm Watts/cfm Measured Airflow: Total cfm Rated Tons cfrn/ton�f ;� — cfrn/ton J M Yes 1 ❑ No I Measured airflow is greater than the criteria in Table RE -2 I J a oass I Pass I Fail E13MAXIMUM COOLING CAPACITY Procedures for determining maximum cooling load canacity are available in RACM. Avvendix RF3. 1 J ❑ Yes ❑ No Adequate airflow verified (see adequate airflow credit) Refrigerant charge or TXV 2 J ❑ Yes ❑ No 3 J ❑ Yes ❑ No Duct leakage reduction credit verified Cooling capacities of installed systems are <_ to maximum cooling capacity indicated on the Performance's CF -1R and RF -3. 4 J ❑ Yes ❑ No 5 J ❑ Yes ❑ No If the cooling capacities of installed systems are > than maximum cooling capacity in the CF -1R, then the electrical input for the installed systems must be:5 to electrical input in the CF -1R. Yes to 1, 2 and 3; and Yes to either 4 or 5 is a pass Pass Fail ,1[1 HIIGH PIER AIR CONDITIONER Procedures or veri tcation are available in RACM, Appendix RI. 1 d ❑ Yes ❑ No EER values of installed systems match the CF -1R 2 ✓ ❑ Yes ❑ No Fors lit system, indoor coil is matched to outdoor coil ✓ d 3 ✓ ❑ Yes ❑ No Time Delay Relay Verified (If Required) Yes to I and 2; and 3 If Required) is a pass Pass Fail Installing Subcontractor o. Name) OR G ra Contractor (Co. Nam R O Signatu : Date: c= Copies to: BUILDING tDEPA1R'1SSC, HERS RATER (IF APPLICABLE) BUILDING OWNER AT OCCUPANCY Residential Compliance Forms April 2005 IIl TAILILATION C Ell TE F)«AT E r Pepe 9 of Rn (CIF -6R 11 Site Address ?���3 ���� � ��� Permit Number C 60���" �� /�,2,-7z2 �26 6 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 must be provided to the building department (upon request) and the building owner at occupancy, per Section 10-103(a). BUIL DENG ENVELOPE LEAKAGE DEAAGNOS' ICS Zf JIEINVELO PIE SEALING IINIFIILTRAT10 N RE11DucTIIO N Procedures for field verification and diagnostic testing of envelope leakage are available in RACM,, Appendix RC. Diagnostic Testing Results Building Envelope Leakage (CFM @ 50 Pa) as measured by Rater: 1 ® Measured envelope leakage less than or equal to the required level from Yej&f No CF -IR? 2. Is Mechanical Ventilation shown as required on the CF -1R? Yesp 4, No 2aorl [T If Mechanical Ventilation is required on the CF -IR (`Yes' in line 2), has it Yes No been installed? ® Check this box `yes' if mechanical ventilation is required (`Yes' in line 2) 2b. Yes No and ventilation fan watts are no greater than shown on CF -1R. Measured Watts= ® Check this box "yes" if measured building infiltration (CFM @ 50 Pa) is 3. greater than the CFM @ 50 values shown for an SLA of 1.5 on CF -1R Yes No If this box is checked no, mechanical ventilation is required.) eck this box "yes" if measured building infiltration (CFM @ 50 Pa) is 4 ® less than the CFM @ 50 values shown for an SLA of 1.5 on CF -IR, Yes No mechanical ventilation is installed and house pressure is greater than minus 5 Pascal with all exhaust fans operating. Pass if: a. Yes in line 1 and line 3, or d d b. Yes in line 1 and line2, 2a, and 2b, or c. Yes in line 1 and Yes in line 4. Otherwise fail. Pass Fail Ir 1, the undersigned, verify that the building envelope leakage meets the requirements claimed for building leakage reduction below default assumptions as used for compliance on the CF -IR. This is to certify that the above diagnostic test results and the work I performed associated with the test(s) is in conformance with the requirements for compliance credit. (The builder shall provide the HERS provider a copy of the CF -6R signed by the builder employees or subcontractors certifying that diagnostic testing and installation meet the requirements for compliance credit.) Test Performed Installing Subcontracto o. Name) OR General s% 6 Contractor (Co. Nam OR O Sign re: Date: Copies to: BUILDING DEPARTMENT, HERS RATER (IIF APPLICABLE), BUILDING OWNER AT OCCUPANCY Residential Compliance Forms April2005 E1STALILATI ON cCIE][ TIEFE CATS aige io of n) (SIF -6R Site Address ® 3 9 Permit Number f 7> Ofl ff nStri IBRIN01M QUEBAtty Ce]I�ttlll Cgltte ✓ Description of Insulation, (CF -6R, formerly IC -1) signed by the installer stating: insulation manufacturer's name, material identification, installed R -values, and for loose -fill insulation: minimum weight per square foot and minimum inches V'k Installation meets all applicable requirements as specified in the High Quality Insulation Installation Procedures (ACM, Appendix RH) ✓ R 11 1-1 All floor joist cavity insulation installed to uniformly fit the cavity side-to-side and end-to-end Yes o NA 11 Yes El insulationin contact with the subfloor or rim joists insulated o NA ❑ Yes I No ❑ NA Insulation properly supported to avoid gaps, voids, and compression V�ALLS ❑ ❑ Wall stud cavities caulked or foamed to provide an air tight envelope Yes No NA [J ❑ Wall stud cavity insulation uniformly fills the cavity side-to-side, top -to -bottom, and front -to -back Yes o NA ❑ Yes o ❑ NA No gaps ❑ ❑ No voids over 3/4" deep or more than 10% of the batt surface area. Yes o NA ❑ ❑ Hard to access wall stud cavities such as; corner channels, wall intersections, and behind Yes e1qo NA tub/shower enclosures insulated to proper R -Value ❑ Yes o ❑ NA Small spaces filled IT ❑ Yes No ❑ NA Rim joists insulated ❑ ❑ ❑ Loose fill wall insulation meets or exceeds manufacturer's minimum weight -per -square -foot Yes 1 No NA requirement UC1EIILt NG ]PRE]PARAT11ON ❑ Yes No ❑ NA All draft stops in place to form a continuous ceiling and wall air barrier ❑ Yes o ❑ NA All drops covered with hard covers ,z7 El ❑ All draft stops and hard covers caulked or foamed to provide an air tight envelope Yes,eNo NA ❑ All recessed light fixtures IC and air tight (AT) rated and sealed with a gasket or caulk between the Yes 40 NA housing and the ceiling ❑ Yes No ❑ NA Floor cavities on multiple -story buildings have air tight draft stops to all adjoining attics ❑ Eave vents prepared for blown insulation - maintain net free -ventilation area Yes o NA ❑ Knee walls insulated or prepared for blown insulation Yes o NA Yes No ❑ NA Area under equipment platforms and cat -walks insulated or accessible for blown insulation ff ❑ Yes No ❑ NA Attic rulers installed Residential Compliance Forms April 2005 INSTALLATION ION cCIElE TI FI[cCAT E (Faire a R of n) Site Address Permit Number ROG]F.WEI LRNG BATTS IV ❑ ❑ Signature: Yes o NA No gaps ❑ ❑ Yes o NA No voids over % in. deep or more than 10% of the batt surface area. ❑ ❑ Yes No NA Insulation in contact with the air -barrier ❑ ❑ Yes o NA Recessed light fixtures covered ❑ ❑ Net free -ventilation area maintained at eave vents Yes No I NA /CIES LIING LOOSE -FILL vir ❑ ❑ Yes o NA Insulation uniformly covers the entire ceiling (or roof) area from the outside of all exterior walls. ❑ ❑ Yes No NA Baffles installed at eaves vents or soffit vents - maintain net free -ventilation area of eave vent W ❑ ❑ Yes JNo NA Attic access insulated Ye No NA Recessed light fixtures covered ❑ ❑ Yes No NA Insulation at proper depth — insulation rulers visible and indicating proper depth and R -value ❑ ❑ ❑ Loose -fill insulation meets or exceeds manufacturer's minimum weight and thickness requirements Yes No NA for the target R -value. Target R -value . Manufacturer's minimum required weight for the target R -value (pounds -per -square -fool). Manufacturer's minimum required thickness at time of installation . Manufacturer's minimum required settled thickness . Note: To receive compliance credit the HERS rater shall verb that the manufacturer's minimum weight and thickness has been achieved for the target R -value. CF -6R only) D TION I hereby certify that the installation meets all applicable requirements as specified in the Insulation Installation Procedures. Installing Subcontractor W6. Name) OR Gen 1 Contractor Co. NamXIR Own Signature: Date: Copies to: BUILDING DEPARTMENT, HERS RAVER (IF APPLICABLE), BUILDING LIIDIIING GdYNER AT OCCUPANCY Residential Compliance Forms April 2005 Description of ffnnsuNttion (lForrnnerlly >«-1 Form) 1. RAISED FLOOR Material ev,41, Thickness (inches) 2. SLAB FLOOR/PERIME Material !& 0 r Thickness (inches) Perimeter Insulation Depth (inches) 3. EXTERIOR WALL Frame Type (7 A. Cavity Insulation Material Thickness (inches) B . Exterior Foam Sheathing Material Thickness (inches) 4. FOUNDATION WALL Material Thickness (inches)'" Brand Name Thermal Resistance (R -Value) Brand Name ' Thermal Resistance (R -Value) Brand Name �.I's m Thermal Resistance (R -Valu -7/3 Brand Name Thermal Resistance (R -Value) Brand Name c7� Thermal Resistance (R -Value) / 2 CEILING Batt or Blanket Type Brand Name Thickness (inches) '' Thermal Resistance (R -Value)' Loose Fill Type Brand Contractor's min installed weightlftz lb Minimum thickness inches Manufacturer's installed weight per square foot to achieve Thermal Resistance (R -Value) 6. ROOF Material Thickness (inchd) / Decllairaflolm Brand Name Q Thermal Resistance (R- slue) ® I hereby certify that the above insulation was installed in the building at the above location in conformance with the current 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 talling Subcontractor (Co. Name) OR General Contractor (Co. Name) OR Owner OR Window Distributor Item #s Signature Date Installing Subcontractor (Co. Name) OR (if applicable) General Contractor (Co. Name) OR Owner OR Window Distributor Item #s Signature ate 3 Installing Subcontractor (Co. Name) OR (if applicable) General Contractor (Co. Name) OR Owner OR Window Distributor Residential Compliance Forms April 2005 Building Department • CITY OF CUPOTE4 0 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 CUP ERT I N® TELEPHONE: (408) 777-3228 • FAX (408) 777--3333 SPE, CIA L INSPECMON AND TFSTIING AGRZE i911CNT Project Name: 07'69 nAW A At 1- Date: 2-5-11 ProjectAddress-. 2aZa3 CA toPp a f. Cali Q7'tit�d Permit #: � ���� To permit applicants of projects requiring Special Inspection and/or Testing per CBC Section 1704: BEFORE A PERMIT CAN BE ISSUED: The Owner, General Contractor, Project Architmt/Engineer and Special inspector shall acknowledgethe required special inspections, testing and conditions. When determined by the Building Inspection Division, a pre -construction conference with the parties involved will be held to review the special inspection requirements and procedures. Special inspection and testing shall meet the minimum requirements of CBC 1704. The following conditions are also applicable: 1. Contractor is responsible for notification to the Special Inspector or Agency regarding individual inspections for times listed on the attached Schedule and noted on the City approved plans. Adequate notice shall be provided so the Special Inspector has time to become familiar with the project and do a thorough job for all inspections. 2. Each Special Inspector shall submit his qualifications to the City and is subject to a personal interview for pre -qualification. Special luspectors shall display an approved identification badge when performing the function of o special inspector or upon request, and frust have a valid ICBG Certification for the type of work being inspected. 3. Duties and Responsibilities of the Special Inspector are: A. Observe the work for conformance with the CITY APPROVED (stumped) design drawings and specifications and applicable workmanship provisions of the CBC - NOTE: Shop drawings may be used only as an aid to inspection,. B. Bring non -conforming items to the immediate attention ofthe contractor and note in daily report (Ref. Item 4). If any such item is not resolved in a timely manner, or is about to be incorporated in the work, notify the Building Inspection Division and the Project Engineer or Architect immediately by telephone at 408=777-3228, or in person. \� n. i Special Inspection and Testing Agreement C. Furnish reports of tests and inspections directly to the Building Inspection Division, Engineer and Architect of record and others as designated. These reports are to include the following: d Describe inspections and test made with applicable locations u List all non -conforming items d Indicate how non -conforming items were resolved or indicate unresolved items as applicable ■ Itemize changes authorized by Architect, Engineer, and Building Inspection Division, if not included in non-conformance items D. Insure that an adequate number of pre -qualified special inspection personnel are on the job, based on the intensity of activities, qnality of work performed and the various operations occurring. E. Submit a FINAL LETTER OF COMPLETION to the Building Inspection Division stating that, to the best of his knowledge, all items requiring special inspection and testing were accomplished, approved and reported in conformance with the approved design drawings, specifications, approved change order and the applicable workmanship provisions of the. CBC. Items not in conformance, unresolved items or any discrepancies in inspection coverage (Le. missed inspections, "periodic' inspections performed when "continuous" inspections were required, etc.) shall be specially itemized in this report. F. FINAL LETTER OF COMPLETION shall be signed by the Licensed Registered Engineer of the Special Inspection Agency of record. 4. Each Special Inspector shall complete and sign the Special Inspection Record ofeach day's inspection and provide a daily handwritten report in a format acceptable to the Building Inspection Division (to remain at the job site with the contractor for review by the Building Department's Inspector). Content of the daily reports shall be per Item 3C above. 5. Work requiring a special inspection, and the performance of a special inspection, shall be monitored by the City's building inspector. City approval is required prior to placement of concrete. General Contractor shall notify 408-777-3228, 24 hours in advance for each day special inspections will be conducted. G. Special inspections are to be performed on a CQNTINUOUS BASIS. meaning that the SPECIAL INSPECTOR IS ON SITE IN THE GENERAL AREA AT ALL TIMES OBSERVING TETE WORK REQUIRING SPECIAL INSPECTION. Periodic inspections may be approved by the Building Inspection Division and, if approved, shall be noted on the SPECIAL INSPECTION AND TESTING SCHEDULE. 7. Only the City approved Testing Agency of record shall sample, transport and test materials. 8. Only the City approved Special Inspeetion.Agency of record shall provide special inspectors. Independent inspectors may be pre -approved by the Building Inspection Division per. Item 2 above. 'W. a Special Inspection and Testing Agreemeoi 9. BEFORE AN OCCUPANCY PERMIT CAN BE ISSUED: Thr Special Lupectw or Agency shall submk a FINAL LETTER OF COMPLETION, per item 3E above, directly to the Building InspecdonDivisiom 10. Copy of SPECIAL INSPECTION AND TESTING SCEMUL F, SPECIAL INSPECTION AND TESTING AGREL MMMT, SPECIAL. WSPECITON RECORD, and SPECIAL INSPECTION DAILY REPORT, SMALL BE AT THE = SITL. ACMOWL6DGVMiiNTS Owner: General ConmwWr: Special lr spector or Agency: Project Engincer/Amhitea:�j�, Building Inspection Division: 3 Comnanv I i i Building Department QTY OF CUPERTINO r03oatprWFAVHut19 • CU?EX1 NO,CA9SM4.325 CUPERTINb rasPxoNe (srsyTnays' FAX (40)777 TAX SPECIAL IN9MMON AND TESTING Project Address Project Tide To owner of pmjeds requiring Special inspection or testing per Chapter 17 of the 2007 California Building Code, please acknowledge and return to the Cay: BEFORE A PERMIT CAN BE ISSUED: The Owner, or his represmutive ou the advice of the tespansiblo Project Engineer or Architect, shall campletq sign and submit the attached form "Structural Tests and Inspection Schedule" to the Building Department for review and approval. 1bc owner and his general contracto, where applitmblq shall also acknowledge the ioliewlag conditions applicable to Special iaspectiop and/ortesthrg. 1. Contractor 1s responsible for proper notification to the lnspeeting or Testing agency for hems listed. 2. Only the testing laboratory should taloa samples and itansportthem to theft laboratory. 3. Copies of all laboratory reports and inspecdons; are to be sent directly to the City by the Testing Agency. 4. Inspection agency to submit names and qualificarions of on-site special inspectors to the Building Department for approval. 5. The Special Iuspector is under the authority and is responsible to the Building Official. All Inspection concerns and/or problems encountered are to be brought to his atteration Immediately. 6. Special inspectors may be required, as a misitmnm, to provide weekly reports to this department of all inspection activity. 7. It Is the responsibility of the conttactarto review City approved plans fen additional inspection or testing requirements that may be noted. g. BEFORE AN OCCUPANCY PERMIT CAN BE ISSUED: The irtapccdon agency shall submit a statement that all items requiring testing and inspection have been fidfilled and repotted no»'ems not tested and/or inspected shall be noted in this statement. Copy of stattment is to be ntained attbe job site for City`s Building Inspectors roviewpdorto final inspections. ACU6*LmQLMM BY ALL .R7 9 C014CERNED GV ^ " Val"M =JA ItSli Ovmer+s rgnanue Projes[��et "`"'7N/ SIBaWure 'fje_'.}ting/(pspectiaq,�geocy Sigrwturo f Cootsaetot's signore Signature 4 Revised VI6l09 Mdshg Department CfIT OF CUpMaWo CUPERTItdO t0�7ORRE AVE%=-CLPMWO"CA9 4,W rFLEFKW E(908)777-3= • EAx: (0 777-M STRUCTURAL TESTS AND INSPECTIONS SCHIMULE Prior to issuance of a building permit, the Owner, on.the advice of the Architector Engineer, shall coatplete, sign and submit this form to the building OfWal. Project02-S CAI"&!& CT Oat SPS" ly/oDn Project Address Tas'a InspectiaoAgency (1 Il 4�11 404(W4 Owner's Name1 / n Owner hereby ca tifies uZ..awthat the TestiagtInspection Aghbeen engaged to perform structural tests and inspections during construction, as checked below, to sad* all applicable portions of the Building Code. Prior to issuance of an occapaucy permit, the inspection Agency shall submit a garoment that all items of designated work performed were reported Any items checked, but not test or inspected, will be noted and explained. Whenever any desiguamd items on this list arcready for sampling, testing or iospection, it shall be the responsibility of the Contractor to give timelymotim to the Inspection Agency so that the required services may he performed REINFORCING STEEL: SIIWCTURAL STEEL: Tend. &. Bond, ane at per be iper tam _Sample& Tea Qirt spxlfio ni mban below) raspacdon orPloeatomt __4»p 7denhfi.Uaa & Waldbg latpcnioa _TagU4GnofWeldtag —Shop Urtrm ietaspedian —SbepRndiogrpby t.4tsomr. Fldd. Welding laspecdan Prefimmay A ---Fm- Tem (MasonryUM-, wallPdma) --Field Boating inspectoa _Subsequega Test(Mmmr, GroM Meld Wag Primes) _Metal Deck Welding IWcWoa Inspection of Grouting _ _)ospeedon of Plaeeaiem & Groudng ASP14lLTIC CONCRETE INSULATING CONCREM MiXI)CSI na Sompla&Test _ Inspection of Batab Plant _ Uoir Weigbrs CaaJIFs1 Field Inspection _Suiab1I4 Tam Specific Gravi —_ ty _Asphdttoateot _ Seve Analysis K Factors Smbflometer value L _SWdI