Loading...
B-2016-1838I CITY OF CUPERTINO BUILDING PERMIT I BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2016-1838 10584 JOHNSON AVE CUPERTINO, CA 95014-3816 (375 28 03 1) JOSHUA CONSTRUCTION &I REMODELING INC I CUPERTINO, CA 95914 ! OWNER'S NAME: HU HONGQI ET AL ( 1 1 DATE ISSUED: 08/11/2016 OWNER'S PHONE: 408-802-4052 101 IN D100 01 INt_AT-ft 1111,43 IIXGJ WARA,111 V 0XIII License Class a Lic. #IQIM Contractor JOSHUA CONSTRUCTION & REMODELING INC Date 12/31/2017 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. aby affirm under penalty of perjury one of the following two declarations: 1. I have and will maintain a certificate of consent to self -insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. t ' 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. Date 12/22/2016 I hereby affirm that I am exempt from the Contractor's Li ense Law for one of the following two reasons: (' 1. I, as owner of the property, or in; employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) 2. I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three declarations: 1. I have and will maintain a Certificate of Consent to self -insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 2. I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 3. 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. APPL•IC.ANT CERTIFICATION I certifythat 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 1 212 2/2 01 6 NO: (408) 8024052 U11 BLDG Y ELECT , PLUMB MECH YX RESIDENTIAL — COMMERCIAL JOB DESCRIPTIQN: NEW 2 STORY SF jjjjjj»���> 1984 SQ FT; NEW GARAGE 428 SQ FT; PATIO/DECK 466 $Q FT *REV # 1 - UPGRADE PANEL (200 AMP);REPLACE (5) WINDOWS & (1) SKYLIGHT; RELOCATE TANKLES WATER HEATER TO GARAGE; ADD MECHANIC SHAFT; 2ND FLOOR- BALCONY REPLACE RAILING TO STIJ CO; GUEST BATH REPLACE SWING DOOR WITH POCKET DOOR - SSUED 12/22/2016 Ft Floor Area: 2412 ( Valuation: $320000.00 APN Number: Occupancy Type: 375 28 031 R-3 (Custom),R-3 (Custom),U (Private Gar /Ag Bldg),U (Private Gar t Ag Bldg) PERMIT EIRES IF WORK IS NOT STARTED WITHIN 18 DAYS OF PERMIT ISSUANCE OR 180 DAYS F OM LAST CALLED INSPECTION. by: RE -ROOFS: Alt roofs sballbe insit oted prior to any roofing material being installed. If a roof is installed without firsttaining an inspection, I agree to remove all new materials for inspection. Signature of Applicant:) Date: 12/2 /2016 "A" OR HAiARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health Safety Code, Sections 25505, 25533, and 25534.1 win maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &Safety C¢de, Section 25532(a) should I store or handle hazardous material. Additionai" should I use equipment or devices which emit hazardous air contaminants as d fined by the Bay Area Air Quality Management District I will maintain compliaptce with the Cupertino Municipal Code, Chapter -9-12 and the Health Safety Code, Sections 25505, 25533, and 25534 Owner or authorized agei . Date: 12/2212016 CONSTRUCTION LENDING AGENCY I hereby affirm that th re is a construction lending agency for the performance of work's for which thi� permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Address l ARCHITECT'S DECLARATjON I understand my plan shall be used as public records. rN CUPERTINO- CONSTRUCTION PERMIT APPLICAT [ON COMMUNiT Y DEVELOPMENT DEPARTMENT - SUILDI VISION # 10300 TORRE AVENUE - CUPERTINO, CA 95014-3265 B (408) 777-3228, FAX (408) 777-3333 - buildino0cupet" (nny-mms T -rT:P A TI nV I TT PROJECTAJ)DRE- --- -- "d. ' P4 Ave- 21, 0�51_ ow-ka xkl-m — PHONE E_KUL T SM&S 2CITY 7 YI�A�IF I FAX CONTACT NAME(PHONE E -?2 SL - STREET ADDREESS CITY, STATE, ZIP FAX ❑ ov'q,'Ep D ow"-ER-BuammCC`1_M4CT0R 'N'T CORACTOlt AGEN-F 10 APCHEIECT 0 )ENON-tER ❑E),E\—.L0_PE:R CONTPLACTORNAME; LIM LICENSTE: ME; Bus. LTC 1 �4*A FPS STREET AA-IDRZSS rt� WOO CAICAI'Vlt I/0" , CITY'STATE'ZI? ,kRc.-TEr_Trr.Nc,LhE:ER XWIAE LICENSE NFLA4EIER BUS,LIC4 CONTANYNAME , /1. f RRrr i ri-MWI,A v A110t) 649 /Y) FAX STREET ADDRESS I CITY, STATE4ZIP '5ay4/4,4�-q V 49-9t2 ,J "Tr7POM _PKSQ_PVa W&f-P-P- heQ44,, A-UlfiPiT �'eefi. oia6f P'0 -Y - bt'r tXISTENGUSE PROPOSFE)USE _1WF_ WSTORIES USE TYPE occ. -CC S.F. T ;Q FT Q VALUAT104 (S) EXISTO 'TRW YLOOR DEN150 TOTAL AY -EA 13ATIIPOOM KTJICFEhl OTHER P—E-MOnELI AF_rA REMODEL AREA RE140DELAREA GAYAGBAPF_1,1. Ll DEIACII C3 ATTACK .]I)ECKARBA *D',XTL1.W'(3 UNITS.' ISASEPCOINDUNIT Q S SECOns-roRv C]' Ts BENGADDEDI E3,40 ADI)ITION7 X-C P FFEE,1,T)ON E]ITS Fr YES; PROVIoFt COPY OF IS THE BLDG AN 13 YES 111 )3. TOTAL VALUATION: LETT m EICHLER POME? By m), signature below, I certif'Y to each of the following- 121)) the Property on-zl d agent to act Oil the -0ropert), owner's behalf. I have -cad ibis application and the information.I have provided is correct. Ihave read the Description cy,'Work and verify litiszccurate. lam-e-tocomply with all applicable local ordinances and state latus rehitir-ou p%nposes. D�te: J/ Ne -,v SFD or Multifanhily dwallin.m Apply for demolition pe,}'71tfor existmEbuildhwsl Demolition pen -nit is required prior to Issua',=_ ofbvillding a m !tO'"'T b, P, Tor - bi Iildinv. gn m, pe.lnlnc EPrOvie- a c0llpieazardo. Disclosu- 4T '_fF k ...-CornmerciPI .. ' �U2 Copy of PlaTming Approval Letter or Mcctij,Z with PIPnnin a prior to ip-, aT Nlrr_"R)�SE Pell)itapplicat)on. si2biiiitfalofB,.)i)diD-l M B1,'&4pp_2011:dvc i-eWsed 061-2)111 t CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2016-1838 10584 JOHNSON AVE CUPERTINO, CA 95014-3816 (375 28 03 1) JOSHUA CONSTRUCTION & REMODELING INC CUPERTINO, CA 95014 OWNER'S NAME: HU HONGQI ET AL DATE ISSUED: 08/11/2016 OWNER'S PHONE: 408-656-9987 PHONE NO: (408) 802-4052 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class GENERAL BUILDING CONTRACTOR Lic. #1010008 Contractor JOSHUA CONSTRUCTION & REMODELING INCDate 12/31/2017 X BLDG _ ELECT _ PLUMB I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing MECH X RESIDENTIAL COMMERCIAL with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. JOB DESCRIPTION: NEW 2 STORY SFD 1984 SQ FT; NEW GARAGE 428 SQ FT; I hereby affirm under penalty of perjury one of the following two declarations: PATIO/DECK 466 SQ FT t. I have and will maintain a certificate of consent to self -insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. Sq. Ft Floor Area: 2412 Valuation: $320000.00 APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances APN Number: Occupancy Type: and state laws relating to building construction, and hereby authorize 375 28 031 R-3 (Custom),R-3 (Custom),U (Private Gar / Ag Bldg),U representatives of this city to enter upon the above mentioned property for (Private Gar / Ag Bldg) 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. PERMIT EXPIRES IF WORK IS NOT STARTED Additionally, the applicant understands and will comply with all non -point WITHIN 180 DAYS OF PERMIT ISSUANCE OR source regulations per the Cupertino Municipal Code, Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. Signature �%" ate 08/11/2016 Issued by: Kim Dunbar OWNER -BUILDER DECLARATION Date: 08/11/2016 I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 1. I, as owner of the property, or my employees with wages as their sole RE -ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is compensation, will do the work, and the structure is not intended or offered for installed without first obtaining an inspection, I agree to remove all new materials for sale (Sec.7044, Business & Professions Code) inspection. 2. I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). Signature of Applicant: Date: 08/11/2016 I hereby affirm under penalty of perjury one of the following three declarations: 1. I have and will maintain a Certificate of Consent to self -insure for Worker's ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 2. I have and will maintain Worker's Compensation Insurance, as provided for by HAZARDOUS MATERIALS DISCLOSURE Section 3700 of the Labor Code, for the performance of the work for which this I have read the hazardous materials requirements under Chapter 6.95 of the permit is issued. California Health & Safety Code, Sections 25505, 25533, and 25534. I will 3. I certify that in the performance of the work for which this permit is issued, I maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the shall not employ any person in any manner so as to become subject to the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous Worker's Compensation laws of California. If, after making this certificate of air contaminants as defined by the Bay Area Air Quality Management District I exemption, I become subject to the Worker's Compensation provisions of the will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and Labor Code, I must forthwith comply with such provisions or this permit shall the Health & Safety Code, Sections 25505, 25533, and 2554. be deemed revoked. APPLICANT CERTIFICATION Owner or authorized agent: I certify that I have read this application and state that the above information is Date: 08/11/2016 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 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance to enter upon the above mentioned property for inspection purposes. (We) agree of work's for which this permit is issued (Sec. 3097, Civ C.) to save indemnify and keep harmless the City of Cupertino against liabilities, Lender's Name judgments, costs, and expenses which may accrue against said City in Lender's Address consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION Code, Section 9.18. I understand my plans shall be used as public records. Signature Date 08/11/2016 Licensed CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 ]CUPERTINO � (408) 777-3228 • FAX (408) 777-3333 • build ing(ct-cupertino,orct � �(P 1 1 NF.W f nV!ZTPI1rq Fn7.T 1 1 A nnr'rTnTzr 1 I A T TT n ATT!\Ti i— n U0 - PROJECT ADDRESS 0 Li a a:avvu a rc JAPN # OWNER NAME r ^ l t , i t ! PHONE 4�) nLj (,56 "(Cy p-7 -1 D E-MAIL STREET ADDRESS C ©� G c -i �) o�J k� CITY, STATE,, ZIP cJ 'i 1 r� Qi �c� f FAX CONTACT NAME PHONE E-MAIL STREET ADDRESS CITY, STATE, ZIP FAX ❑ OWNER ❑ OWNRR-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT' ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARCHITEC'r/BNGINEER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME E iV1AIL FAX r STREET ADDRESS l rZL�{y D' CITY, STATE, ZIP `bin 2 c CIS2 G PHONE S DESCRIPTION OF WORK (-t G S 1 L-lS C W (To G g - t+ to - EXISTING USE PROPOSED USE CONSTR. TYPE # S?'ORlES 1I" USE TYPE OCC. SQ.FT. VALUATION (S) EXIST AREA f04% f0 �o4% AREANEW '�-�kl`2- AREA lo�f�- rOTAL NET AREA 2�{-l2 S�IZ- v � {2�j iQFSy- BATHROOM REMODBL AREA KITCHEN REMODEL AREA OTHER REMODEL AREA r� t ��� A0-AVle y� v L5T (' J v L f_2 (�- t'�" � ( 0_6-0-0 PORCH AREA DECK AREA TOTAL DECK/PORCH AREA LS 1111ARL•A: DETACH [ A7 TACH r (� p 4" 4 o G� C- 0 r 'C 2 � ((��,,�� � ATi Ujl%1 L �/ t7 i—`�j 3 to 0_tr_L7 # DWELLING UNITS: I5 A SECOND UNrr ❑ YES SECOND STORY ®YES I BEING ADDED? PNO ADDITION? ONO PRE -APPLICATION '� YES IF YES, PROVIDE COPY Of F PLANNING APPL # NO PLANNING APPROVAL LETTER IS THE ELDC AN YES EICHLER HOME? RE _ EIVEDBY TOTAL VALUATION: UFNO By my signature below, I certify to each of the following: I am the property owner or authorized agent 0 act oA the property owner's behalf. I have read this application and the information I have provided is correct. 1 have read the Description of Work and verify it is accurate. 1 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: Date: i fr' 2,.71 `— f ro SUPPLE MENTALI INFORMATION REQUIRED PLA N c1TEc1C TYPE RoiiTTNc.scrr ❑: pVER_TBE COUNTER ❑ BUILDING PLAN REVIE1. W _ New SFD or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building `;, �Ox* permit for new building. ❑ EXPRESS ❑ PLANNING I'LAN REVIEW _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure =❑` 3TA.NUARD ❑. PUBLIC WORKS form if any Hazardous Materials are being used as part of this project. LARGE ❑ FIRE.DEPT'=' _ Copy of Planning Approval Letter or Meeting with Planning prior to 1_ 17` MAJOR ❑ sANITARx SEWER nISTRtcrjtttA submittal of Building Permit application. ❑ ENVIRONMENTALWALTH BldgApp_2011.doc rmised 06/21/11 yaV CAPEX ENGINEERING INC. PO BOX 14198, FREMONT, CA 94539 Tel: (510) 668-1815 Fax: (510) 490-8690 August 30, 2016 Project No. 10619 Building Department City of Cupertino 10300 Torre Ave. r Cupertino, CA 95014 a Subject: Proposed New Residence at 10584 Johnson Ave. Cupertino, CA FOOTING EXCAVATION (GRADE BEAMS & SPREAD FOOTINGS) AND PREPARATION OBSERVATION REPORT Dear Sir: CAPEX ENGINEERING INC., has provided inspection service for footing excavation and preparation. Footing depth and width were excavated adequate in accordance with approved foundation plan and specifications. The exposed soil conditions of excavated foundation are beyond design bearing capaci Any questions, please call our office at your Sincerely, C EX E GINEERING INC., Gary su, .E Principal 1-1 - - , — CAPER ENGINEERING INC. PO BOX 14198, FREMONT, CA 94539 Tel: (510) 668-1815 Fax: (510) 490-8690 77 11— Lula August 30, 2016 Project No. 10619 Building Department City of Cupertino y ' 10300 Torre Ave. V Cupertino, CA 95014 r, Subject: Proposed New Residence at 10584 Johnson Ave. Cupertino, CA SITE DEMOLITION AND BUILDING xPAD GRADING OBSERVATION REPORT Dear Sir: CAPEX ENGINEERING INC., has provided observation service for site demolition, primary and final grading of building pad. On the basis of our observation and testing, we concluded building pad, compaction operation was performed in general accordance with recommendation of soil report and compacted to a minimum of 90% relative compaction. If you have any questions, please contact our office at your convenience. Sincerely, CAPEX ENGINEERING INC., (A Gary su, .E Principal Q�OfESSIQ 0o C* a 9 INL RW Engineering, Inc. Civil Engineers • Land Surveyors 505 Altamont Drive, Milpitas, CA 95035 Tel: (408)262-1899 Fax: (408) 824-5556 Email: rwengineering@gmail.com August 30, 2016 City of Cupertino — Building Division 10300 Torre Avenue Cupertino, CA 95014-3202 Re: Building setback verification Project Site: 10584. Johnson Ave., Cupertino, CA To Whom It May Concern: This is to confirm that the foundation forms for the above -referenced project comply with the setback requirements as shown on the approved plan. Please feel free to call me if you have any questions. Sincerely. P.E., P.L.S. Z-'' '�/ � RD Design and Englineerinlu t!� t� Residential Design and Structural Engiii-neering 1570 Mission Avenida Morgan Hill, CA 955037 Phone: (408) 605-8859 Email- Wstructural(d)yahoo.com I December I 9 2016 I x- t t e r No Property Owner Sub ject: FINAL FRAMING OBSERVATION A'F-. 17� 105 94 Johnson, CUr)ertino. CA Dear Propeny 0-%vner, HD Desimi and Engineering J II:` performed structural framing, observations on Decimiter Z=- - 19. 20 16 to insure structural f rarnirig comp! led witli approved plan. "I'lic observations covered cit` conanleted2"'I'loor framino and l" flooring framing io foundation, HDDE (lid not lIndu)y mzt�or deficiency and recommend approving final fi�aniim-). excepting (2) modified Itemis and approved as stated: I SS'FB24 hold,own anchor bolts have mistakell installing fior FIDI,'-5- Theanchor bolts ornitted and requested to install (5) new 7/8-diarneter all threaded nods in drilled holes epoxied by nsing Siml)son Al' -XP 1'poxy Compound. The drilled holes (trilled thl-OU"ll stern and approximately to bottom of rooting, -- IV, well c1can of debris. dried. anl installed fcdlowing manufacture's recommendation. IIDDEapproved to anchors to replace the SSTB28, cast in place 1'(-)r connecting 2. Detail ')/ S requested usi ng A35 con nectim-, the 2x W ocki rig bety-veen rafters to exlc ri or N,vatl top plates. Due to- lar ger gap between '? elements, framer C1100SC Ubing L.S,',',:k to re anal approvedI T tip reviewed a place A35 clips. IJDDE f i Should pu h-ve any questions, please feel frecto contact our office. Hoe Doan, P. -E. Principal offlgug�� Building Deparallent Fax: 40o'-77-7-; CONTRACTOR StJBCONTRACTOR I AST .. . .. ................ I A D 1) R 1: SS /0tu o J -Z .... Av.Q . %k N I - WS :RANI I III I ON, I CiFNE],"Al, ('(Y'' IRA(- FOP:'f�jj�-S 91'Ni I- S�- i. I (I N S I I') I') f I le(q 4 Y- . . ........... . ... .... ... ]-(A C Jf2A zrr,(� 151": /11 j�4 "'Our ulkilli6pal code �,alj Imshlesses %�oyldwr ill thecih to have a (AiN of, Cupertillo busincs's license. 'SO BUILDING FINAL OR FINAL OCCUPANCY INSPE(: TIoNts) t� (-;I I GFINIFANIAL CON' UR kCTOR AND AIA s1, 1W () N, F R 11) R S I L"T I I -A I N E I A CITY OF CI 1) F' KI IN BUSF\FSS LWV�Nsk`- I mll not lasing mll --------- sionature Dale Please check applicable and complete Me following informasion, SI I. LIC LEST Pf' :2 0 //Oa . . . . ............... ..... ... . . . (ze Owner ("ontractor 21laturk, fI'?USI'NFSANIF', Cabinet:,, & INfillwork ....... . ... ........... .. . . ............... ..... ...... - -------------- -- C'2,111enk Fini"JIMU - — --------- --- - Flcctrictl ............ ........ ..... . va t 1011 . . .. . ........ . . .......... . Hoorinu, Carpctin,2 ............... . .. Linolcum Wood 1 Glass Glazin" . .......... . A -)Y InsulatIO11 NI ason ry Painting \,Va I I jx�l Pk2 V ... ...... ... (y^ 0 2 I'laster'HIL, - — -------- Roofin 'co Septic: F"alk, . . .... - - ------- - - - Sheet Riwk SI I. LIC LEST Pf' :2 0 //Oa . . . . ............... ..... ... . . . (ze Owner ("ontractor 21laturk, FILE� CERTIFICATE OF VERIFICATION CF3R-MCH-20-H Duct Leakage Diagnostic Test (Page 1 of 3 ) Project Name: 10584 Johnson Ave Enforcement Agency: Cupertino City of Permit Number: B2016-1838 Dwelling Address: 10584 Johnson Ave City: Cupertino Zip Code: 95014 A. System Information 01 Space Conditioning System Identification or Name System 1 02 Space Conditioning System Location or Area Served Location 1 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 1 Duct System Compliance Category New MCH -20a - Completely New Duct System B. Duct Leakage Diagnostic Test Condenser Nominal Cooling Capacity (ton) 5 r01 02 Heating Capacity (kBtu/h) 97 03 Conditioned Floor Area served by this HVAC system (ft2) 1984 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) 126 10 Actual duct leakage rate from leakage test measurement (cfm) 86 11 Compliance Statement System passes leakage test Registration Number: 217-A0185296A-M2000002A-M20A Registration Date/Time: 2017-06-0122:14:58 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.008 Report Generated: 2017-06-01 22:12:35 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. 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. 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. 01 Complies: All specified verification protocol requirements on this document are met. Registration Number: 217-A0185296A-M2000002A-M20A Registration Date/Time: 2017-06-0122:14:58 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.008 Report Generated: 2017-06-01 22:12:35 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: Kevin Harry Documentation Author Signature: /f eA,ozfl/ Company: Date Signed: Allied HERS Testing 2017-06-01 22:14:58 Address: CEA/ HERS Certification Identification (if applicable): 853 West L Street CC2006610 City/State/Zip: Phone: Benicia CA 94510 707-373-0196 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. I 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. S. 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): LOTUS AIR CARE Responsible Builder or Installer Name: CSLB License: Long Le 886016 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: Allied HERS Testing Responsible Rater Name: Kevin Harry Responsible Rater Signature: //'' eeemzle, Responsible Rater Certification Number w/ this HERS Provider: Date Signed: CC2006610 2017-06-01 22:14:58 Digitally signed by Ca10ERTS. 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: 217-A0185296A-M2000002A-M20A Registration Date/Time: 2017-06-01 22:14:58 HERS Provider: CalCERTS CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.008 Report Generated: 2017-06-01 22:12:35 2013 Residential Compliance Schema Version: 2013.1.007 CERTIFICATE OF VERIFICATION CF3R-MCH-23-H Space Conditioning System Airflow Rate (Page 1 of 4 ) Project Name: 10584 Johnson Ave Enforcement Agency: Cupertino City of Permit Number: B2016-1838 Dwelling Address: 10584 Johnson Ave City: Cupertino Zip Code: 95014 A. Ducted Cooling System Information 01 System Identification or Name System 1 02 System Location or Area Served Location 1 03 System Installation Type New 04 Nominal Cooling Capacity (tons) of Condenser 5 05 Condenser Speed Type Single Speed 06 Cooling System Zonal Control Type Not Zonal 07 Central Fan Integrated (CFI) Ventilation System Status Not a CFI system 08 System Bypass Duct Status No Bypass Duct 09 Date of System Airflow Rate Measurement 2017-05-31 Fol Airflow Rate Protocol Utilized RA3.3 procedures for airflow rate measurement B. Hole for the placement of a Static Pressure Probe (HSPP), and Permanently Installed Static Pressure Probe (PSPP) in the Supply Plenum. Procedures for installing HSPP or PSPP are specified in RA3.3.1.1. 01 I Method Used to Demonstrate Compliance with the( HSPP installed and labeled consistent with Figure RA3.3-1 HSPP/PSPP Requirement C. Airflow Rate Measurement Apparatus and Procedure Information Instrument Specifications are given in RA3.3.1.1, and system airflow rate measurement apparatus information is given in RA3.3.2. 01 Airflow Rate Measurement Type used for this airflow rate Traditional Flow Capture Hood according to procedure in verification. RA3.3.3.1.4 02 Manufacturer of Airflow Measurement Apparatus Kanomax 03 Model number of Airflow Measurement Apparatus 6710-2 Certification Status of the Airflow Measurement Apparatus Certified by Manufacturer and listed on CEC Website at 04 Accuracy http://www.energy.ca.gov/title24/equipment_cert/ama_fas /index.html Registration Number: 217-A0185296A-M2300002A-M23A Registration Date/Time: 2017-06-01 22:14:58 HERS Provider: CalCERTS CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.008 Report Generated: 2017-06-01 22:13:16 2013 Residential Compliance Schema Version: 2013.1.008 CERTIFICATE OF VERIFICATION CF311-MCH-23-1-1 Space Conditioning System Airflow Rate (Page 2 of 4 ) MCH -23a Forced Air System Airflow Rate Measurement - Newly Installed Non -Zoned Systems or Zoned Multi -Speed Compressor D. Forced Air System Airflow Rate Measurement The procedures for System Airflow Rate Verification are specified in Reference Residential Appendix RA3.3. 01 Required Minimum System Airflow Rate (cfm/ton) 350 02 Required Minimum System Airflow Target (cfm) 1750 03 Actual System Airflow Rate Measurement (cfm) 1755 04 Compliance Statement: System airflow rate complies E. Additional Requirements 01 Air filters that meet the applicable requirements of Standards Section 150.0(m)12 or 150.0(m)13 were properly installed in the system during system air flow rate measurement identified on this Certificate of Verification. The airflow rate measurement apparatus used to perform the airflow rate measurement identified on this Certificate of 02 Verification was calibrated in accordance with the apparatus manufacturer's specifications and conforms to the instrumentation specifications given in RA3.3.1. A visual inspection shall confirm that bypass ducts that deliver conditioned supply air directly to the space conditioning 03 system return duct airflow are not used on newly constructed zonally controlled systems unless the Performance Certificate of Compliance indicates an allowance for use of a bypass duct. When a bypass duct is accounted for on the Performance Certificate of Compliance, the airflow rate shall conform to the specifications listed on the Certificate of Compliance. 04 All registers were fully open during the diagnostic test. 05 System fan was set at maximum speed during the diagnostic test. 06 If fresh air duct is part of the HVAC system it was not closed during the diagnostic test. 07 Airflow rate and fan watt draw shall be simultaneous measurements when used to calculate the Fan Efficacy tested value. Multi -speed compressor space cooling systems or variable speed compressor systems shall verify air flow (cfm/ton) and fan 08 efficacy (Watt/cfm) with system operating in cooling mode at the maximum compressor speed and the maximum air handler fan speed. 09 Verification Status: Pass - all applicable requirements are met 10 Correction Notes: The responsible person's signature on this compliance document affirms that all applicable requirements in this table have been met unless otherwise noted in the Verification Status and the Corrections Notes in this table. Registration Number: 217-A0185296A-M2300002A-M23A Registration Date/Time: 2017-06-01 22:14:58 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.008 Report Generated: 2017-06-01 22:13:16 2013 Residential Compliance Schema Version: 2013.1.008 CERTIFICATE OF VERIFICATION CF3R-MCH-23-H Space Conditioning System Airflow Rate (Page 3 of 4 ) F. Determination of HERS Verification Compliance All applicable sections of this document shall indicate compliance with the specified verification protocol requirements in order for this Certificate of Verification as a whole to be determined to be in compliance. 01 Complies: All specified verification protocol requirements on this document are met. Registration Number: 217-A0185296A-M2300002A-M23A Registration Date/Time: 2017-06-01 22:14:58 HERS Provider: CalCERTS CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.008 Report Generated: 2017-06-01 22:13:16 2013 Residential Compliance Schema Version: 2013.1.008 CERTIFICATE OF VERIFICATION CF3R-MCH-23-H Space Conditioning System Airflow Rate (Page 4 of 4 ) Documentation Author's Declaration Statement 1.1 certify that this Certificate of Verification documentation is accurate and complete. Documentation Author Name: Documentation Author Signature: //'' /Cevz;i�- Kevin Harry Company: Date Signed: Allied HERS Testing 2017-06-01 22:14:58 Address: CEA/ HERS Certification Identification (if applicable): 853 West L Street CC2006610 City/State/Zip: Phone: Benicia CA 94510 707-373-0196 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. S. I 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): LOTUS AIR CARE Responsible Builder or Installer Name: CSLB License: Long Le 886016 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: Allied HERS Testing Responsible Rater Name: Responsible Rater Signature: Kevin Harry Responsible Rater Certification Number w/ this HERS Provider: Date Signed: CC2006610 2017-06-01 22:14:58 Digitally signed by Ca10ERTS. 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: 217-A0185296A-M2300002A-M23A Registration Date/Time: 2017-06-01 22:14:58 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.008 Report Generated: 2017-06-01 22:13:16 2013 Residential Compliance Schema Version: 2013.1.008 CERTIFICATE OF VERIFICATION CF3R-MCH-22-H Space Conditioning System Fan Efficacy (Page 1 of 3 ) Project Name: 10584 Johnson Ave Enforcement Agency: Cupertino City of Permit Number: 82016-1838 Dwelling Address: 10584 Johnson Ave City: Cupertino Zip Code: 95014 A. Ducted Cooling System Information 01 System Identification or Name System 1 02 System Location or Area Served Location 1 03 System Installation Type New 04 Nominal Cooling Capacity (tons) of Condenser 5 05 Condenser Speed Type Single Speed 06 Cooling System Zonal Control Type Not Zonal 07 Central Fan Integrated (CFI) Ventilation System Status Not a CFI system 08 System Bypass Duct Status No Bypass Duct Date of System Airflow Rate Measurement 2017-05-31 E10 Airflow Rate Protocol utilized RA3.3 procedures for airflow rate measurement B. Fan Watt Measurement Apparatus and Procedure Information Instrument Specifications are given in RA3.3.1, and system fan watt measurement apparatus information is given in RA3.3.2.2. 01 1 Fan Watt Verification Device Used. I Portable watt meter MCH -22a Forced Air System Fan Efficacy Measurement - Newly Installed Non -Zoned Systems or Zoned Multi -Speed Compressor C. Forced Air System Fan Efficacy Measurement The procedures for System Fan Watt Verification are specified in Reference Residential Appendix RA3.3. 01 Actual Tested Watts 1010 02 Actual Tested Airflow from MCH -23 (cfm) 1755 03 Required Fan Efficacy (watts/cfm) 0.58 04 Actual Fan Efficacy (watts/cfm) 0.58 05 Compliance Statement: System fan efficacy complies Registration Number: 217-A0185296A-M2200002A-M22A Registration Date/Time: 2017-06-01 22:14:58 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.008 Report Generated: 2017-06-01 22:13:42 2013 Residential Compliance Schema Version: 0.51SDD CERTIFICATE OF VERIFICATION CF3R-MCH-22-H Space Conditioning System Fan Efficacy (Page 2 of 3 ) D. Additional Requirements All registers were fully open during the diagnostic test. 02 r001 System fan was set at maximum speed during the diagnostic test. 3 If fresh air duct is part of the HVAC system it was not closed during the diagnostic test. 04 Airflow rate and fan watt draw shall be simultaneous measurements when used to calculate the Fan Efficacy tested value. 05 Multi -speed compressor space cooling systems or variable speed compressor systems shall verify air flow (cfm/ton) and fan efficacy (Watt/cfm) with system operating in cooling mode at the maximum compressor speed and the maximum air handler fan speed. 06 Zoned cooling air distribution systems with single speed compressors shall meet both the airflow (cfm/ton) and fan efficacy (Watt/cfm) criteria in every zonal control mode. 07 Verification Status Pass - all applicable requirements are met 08 Correction Notes 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. E. 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. 1 01 1 Complies: All specified verification protocol requirements on this document are met. Registration Number: 217-A0185296A-M2200002A-M22A Registration Date/Time: 2017-06-01 22:14:58 HERS Provider: CalCERTS CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.008 Report Generated: 2017-06-01 22:13:42 2013 Residential Compliance Schema Version: 0.51SDD CERTIFICATE OF VERIFICATION CF3R-MCH-22-H Space Conditioning System Fan Efficacy (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: 10,ot!f/ Kevin Harry Company: Date Signed: Allied HERS Testing 2017-06-01 22:14:58 Address: CEA/ HERS Certification Identification (if applicable): 853 West L Street CC2006610 City/State/Zip: Phone: Benicia CA 94510 707-373-0196 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): LOTUS AIR CARE Responsible Builder or Installer Name: CSLB License: Long Le 886016 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: Allied HERS Testing Responsible Rater Name: Responsible Rater Signature: ,(1 Kevin Harry ' `ems Responsible Rater Certification Number w/ this HERS Provider: Date Signed: CC2006610 2017-06-01 22:14:58 Digitally signed by Ca10ERTS. 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: 217-A0185296A-M2200002A-M22A Registration Date/Time: 2017-06-01 22:14:58 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.008 Report Generated: 2017-06-01 22:13:42 2013 Residential Compliance Schema Version: 0.51SDD CERTIFICATE OF VERIFICATION CF3R-MCH-27-H Indoor Air Quality and Mechanical Ventilation (Page 1 of 3 ) Project Name: 10584 Johnson Ave Enforcement Agency: City of Cupertino Permit Number: 82016-1838 Dwelling Address: 10584 Johnson Ave City: Cupertino Zip Code: 95014 Title 24, Part 6, Section 150.0(0) Ventilation for Indoor Air Quality. All dwelling units shall meet the requirements of ANSI/ASHRAE Standard 62.2. Ventilation and Acceptable Indoor Air Quality in Low -Rise Residential Buildings. Equation and table numbering on this form corresponds to the numbering for that information in the published ANSI/SHRAE Standard 62.2-2010. A. Dwelling Mechanical Ventilation - General Information 01 Dwelling unit name 10584 Johnson Ave 02 Building Type Single family 03 Project scope Addition greater than 1,000 ft2 04 Total Conditioned Floor Area of Dwelling Unit (For addition projects the conditioned floor area equals existing area plus addition area. ) 1984 05 Number of bedrooms in dwelling unit (For addition projects the number of bedrooms equals the existing bedrooms plus addition bedrooms) 4 06 Ventilation Operation Schedule Continuous 07 Whole -Building Ventilation Rate Calculation Method Fan Ventilation Rate Method (4.1.1) 08 Whole Building Ventilation System Type Standalone - Exhaust MCH -27a - Continuous Ventilation Airflow - Fan Ventilation Rate Method B. Whole -Building Continuous Ventilation - Fan Ventilation Rate Method 01 Required Continuous Whole -Building Ventilation Rate 57 02 Installed Continuous Whole -Building Ventilation Rate 88 C. Compliance Statement 01 Building passes continuous whole -building ventilation rate test Registration Number: 217-A0185296A-M2700002A-M27A Registration Date/Time: 2017-06-01 22:14:58 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.008 Report Generated: 2017-06-01 22:14:24 2013 Residential Compliance Schema Version: 2013.1.008 CERTIFICATE OF VERIFICATION CF3R-MCH-27-1H Indoor Air Quality and Mechanical Ventilation (Page 2 of 3 ) 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. 1 01 1 Complies: All specified verification protocol requirements on this document are met. Registration Number: 217-A0185296A-M2700002A-M27A Registration Date/Time: 2017-06-01 22:14:58 HERS Provider: CalCERTS CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.008 Report Generated: 2017-06-01 22:14:24 2013 Residential Compliance Schema Version: 2013.1.008 CERTIFICATE OF VERIFICATION CF3R-MCH-27-H Indoor Air Quality and Mechanical Ventilation (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: Kevin Harry Documentation Author Signature: //'' eeie ;v Company: Date Signed: Allied HERS Testing 2017-06-01 22:14:58 Address: CEA/ HERS Certification Identification (if applicable): 853 West L Street Benicia / CA / 94510 City/State/Zip: Phone: Benicia CA 94510 707-373-0196 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): LOTUS AIR CARE Responsible Builder or Installer Name: CSLB License: Long Le 886016 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: Allied HERS Testing Responsible Rater Name: Harry Responsible Rater Signature: /' ea0z;v Kevin Responsible Rater Certification Number w/ this HERS Provider: Date Signed: CC2006610 2017-06-01 22:14:58 Digitally signed by CaICERTS. This digital signature is provided in order to secure the content of this registered document, and in no way implies Registration Provider responsibility for the accuracy of the information. Registration Number: 217-A0185296A-M2700002A-M27A Registration Date/Time: 2017-06-01 22:14:58 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.008 Report Generated: 2017-06-01 22:14:24 2013 Residential Compliance Schema Version: 2013.1.008 CERTIFICATE OF INSTALLATION CF2R-MCH-01-E Space Conditioning Systems, Ducts, and Fans (Page 1 of 8 ) Project Name: 10584 Johnson Ave Enforcement Agency: City of Cupertino Permit Number: 82016-1838 Dwelling Address: 10584 Johnson Ave City: Cupertino Zip Code: 95014 A. General Information 01 Dwelling Unit Name 10584 Johnson Ave 02 Climate Zone 4 07 Dwelling Unit Total Conditioned Floor 09 10 Number of Space Conditioning SC System 03 Area (W) 1984 04 Systems in this Dwelling Unit. 1 OS Certificate of Compliance Type Prescriptive alterations (CF111-ALT) 06 Method used to Calculate HVAC Loads NotApplicableEquipmentChangeout 07 Calculated Dwelling Unit Sensible This field or section is not applicable 08 Calculated Dwelling Unit Heating Load This field or section is not applicable Name Cooling Load (Btuh) System (ft) ducted (Btuh) components? 09 Dwelling Unit Number of Bedrooms 4 MCH -01b Space Conditioning Systems Ducts and Fans - Prescriptive Alterations B. Space Conditioning (SC) System Information 01 02 03 04 05 06 07 08 09 10 SC System SC System CFA served Is the SC Installing a Installing new SC Installing more Installing Installing Identification or Location or Area by this SC systema refrigerantducted system than 40 feet of entirely new entirely new SC Alteration Type Name Served System (ft) ducted containing components? ducts? duct system? system? component? Entirely new or complete System 1 Location 1 1984 Yes Yes Yes Yes Yes Yes replacement space conditioning system Registration Number: 217-A0185296A-M0100002A-0000 Registration Date/Time: 2017-06-01 22:15:52 HERS Provider: CaICERTS CA Building Energy Efficiency Standards - 2013 Residential Compliance Report Version: 2013 Rev 1.008 Report Generated: 2017-06-01 22:05:12 Schema Version: 2013.1.008 CERTIFICATE OF INSTALLATION CF2R-MCH-01-E Space Conditioning Systems, Duds, and Fans (Page 2 of 8 ) C. Space Conditioning (SC) System Alterations Compliance Information 01 02 03 04 05 06 07 08 09 10 11 12 13 Rated Heating Capacity, Output (BTU H) System 1 AFUE 97 Carrier 595C5 21000521-- 5016A47223 97000 Notes: Central Fan Integrated Heating Cooling New or (CFI) System Altered Heating Minimum Altered Cooling Minimum Required Replaced New Ventilation Identification Heating Heating Efficiency Efficiency Cooling Cooling Efficiency Efficiency Thermostat Duct Dud System or Name System Type Component Type I Value System Type Components Type Value Type Length R -Value 1 Status All new All new System 1 Central gas heating AFUE 78 Central cooling SEER 14 Setback GT40Ft R6 Not a CFI furnace componen split AC components system is D. Installed Heating Equipment Information 01 02 03 04 05 06 07 System Identification or Name Heating Efficiency Type Heating Efficiency Value Heating Unit Manufacturer Heating Unit Model Number Heating Unit serial number Rated Heating Capacity, Output (BTU H) System 1 AFUE 97 Carrier 595C5 21000521-- 5016A47223 97000 Notes: Registration Number: 217-A0185296A-M0100002A-0000 Registration Date/Time: 2017-06-01 22:15:52 HERS Provider: CalCERTS CA Building Energy Efficiency Standards - 2013 Residential Compliance Report Version: 2013 Rev 1.008 Report Generated: 2017-06-01 22:05:12 Schema Version: 2013.1.008 CERTIFICATE OF INSTALLATION CF2R-MCH-01-E Space Conditioning Systems, Ducts, and Fans (Page 3 of 8 ) E. Installed Cooling Equipment information 01 02 03 04 05 06 01 02 03 04 05 06 07 08 Method of Condenser or Package Unit Condenser or Condenser or Condenser or System Rated Cooling Condenser Rated System Identification Cooling Efficiency Cooling Efficiency Package Unit Package Unit Package Unit Capacity at Design Nominal Capacity or Name Type Value Manufacturer Model Number Serial Number Conditions (BTUH) (ton) System 1 SEER 14 Carrier 24AAA056OA30 0217EO7745 60000 5 System this system? Notes: Unconditioned Unconditioned F. Extension of Existing Duct System, Greater Than 40 Feet This section does not apply to this project. G. Installed Duct System information 01 02 03 04 05 06 07 08 09 Method of Can RA3.3 compliance with Airflow SC System SC System duct and filter Number of Air Protocols be Identification or Location or Area Supply Duct Supply Duct Return Duct Return Duct grille sizing Req's Filter Devices on used to test Name Served Location R -Value Location R -Value in 150.0(m)13 System this system? HERS verified fan Unconditioned Unconditioned efficacy (W/cfm) System 1 Location 1 garage R-6 garage R-6 and airflow rate 1 Yes (cfm/ton) Notes: Registration Number: 217-A0185296A-M0100002A-0000 Registration Date/Time: 2017-06-01 22:15:52 HERS Provider: CaICERTS CA Building Energy Efficiency Standards - 2013 Residential Compliance Report Version: 2013 Rev 1.008 Report Generated: 2017-06-01 22:05:12 Schema Version: 2013.1.008 CERTIFICATE OF INSTALLATION CF2R-MCH-01-E Space Conditioning Systems, Ducts, and Fans (Page 4 of 8 ) H. Installed Air Filter Device Information 01 02 03 04 05 06 07 SC System Identification or Name SC System Location or Area Served Air Filter Identification or Name Air Filter Device Type Air Filter Device Location Determined Design Airflow Rate for Air Filter Device (cfm) Determined Design Allowable Pressure Drop for Air Filter Device (inch W.C.) System 1 Location 1 Filter 1 Filter Grille Stairwell 2000 1 Notes: I. Air Filter Device Requirements 01 The system shall be designed to ensure that all recirculated air and all outdoor air supplied to the occupiable space is filtered before passing through the system's thermal conditioning components. The system shall be designed to accommodate the clean -filter pressure drop imposed by the system air filter device(s). The design airflow rate and maximum allowable clean -filter pressure drop at the design airflow rate applicable to each airfilter device shall be determined, and all system air filter device locations shall be 02 labeled to disclose the applicable design airflow rate and the maximum allowable clean -filter pressure drop. The labels shall be permanently affixed to the air filter device, readily legible, and visible to a person replacing the air filter media, and the air filter devices shall be provided with air filter media that conforms to these determined or labeled maximum allowable clean -filter pressure drop values as rated using AHRI Standard 680. 03 All system air filter devices shall be located and installed in such a manner as to allow access and regular service by the system owner. 04 The system shall be provided with air filter media having a designated efficiency equal to or greater than MERV 6 when tested in accordance with ASHRAE Standard 52.2, or a particle size efficiency rating equal to or greater than 50 percent in the 3.0 to10 micron range when tested in accordance with AHRI Standard 680. The system shall be provided with air filter media that has been labeled by the manufacturer to disclose the efficiency and pressure drop ratings that conform to the 05 required efficiency and pressure drop requirements for the air filter device. The responsible persons signature on this compliance document affirms that all applicable requirements in this table have been met. Registration Number: 217-A0185296A-M0100002A-0000 Registration Date/Time: 2017-06-01 22:15:52 HERS Provider: CalCERTS CA Building Energy Efficiency Standards - 2013 Residential Compliance Report Version: 2013 Rev 1.008 Report Generated: 2017-06-01 22:05:12 Schema Version: 2013.1.008 CERTIFICATE OF INSTALLATION CF2R-MCH-01-E Space Conditioning Systems, Ducts, and Fans (Page 5 of 8 ) J. HERS Verification Requirements O1 02 03 04 05 06 07 08 09 10 MCH20 MCH21 MCH22 MCH23 MCH25 MCH28 Exemption from Minimum Exemption R -Value for AHU System SC System From Duct Duct Ducts In Ducts Located AHU Fan Airflow Identification or Location or Area Leakage Leakage Conditioned In Cond Space Efficacy Rate Refrigerant Return Duct Design Name Served Requirements Test Space Verification (W/cfm) (cfm/ton) Charge Table 150.0-C or D System 1 Location 1 No exemptions Yes No Exemption No Yes Yes No No Notes: Registration Number: 217-A0185296A-M0100002A-0000 Registration Date/Time: 2017-06-01 22:15:52 HERS Provider: CalCERTS CA Building Energy Efficiency Standards - 2013 Residential Compliance Report Version: 2013 Rev 1.008 Report Generated: 2017-06-01 22:05:12 Schema Version: 2013.1.008 CERTIFICATE OF INSTALLATION CF2R-MCH-01-E Space Conditioning Systems, Ducts, and Fans (Page 6 of 8 ) K. Space Conditioning Systems, Ducts and Fans Mandatory Requirements and Additional Measures Note: Additional mandatory requirements from Section 150.0 that are not listed here may be applicable to some systems. These requirements may be applicable to only newly installed equipment or portions of the system that are altered. Existing equipment may be exempt from these requirements. Heating Equipment Equipment Efficiency: All heating equipment must meet the minimum efficiency requirements of Section 110.1 and Section 110.2(a) and the Appliance Efficiency 01 Regulations. Controls: All unitary heating systems, including heat pumps, must be controlled by a setback thermostat. These thermostats must be capable of allowing the occupant 02 to program the temperature set points for at least four different periods in 24 hours. See Sections 150.0(i), 110.2(b). Sizing: Heating load calculations must be done on portions of the building served by new heating systems to prevent inadvertent undersizing or oversizing. See sections 03 150.0(h)1 and 2). Furnace Temperature Rise: Central forced -air heating furnace installations must be configured to operate at or below the furnace manufacturer's maximum 04 inlet -to -outlet temperature rise specification. See Section 150.0(h)4. 05 Standby Losses and Pilot Lights: Fan -type central furnaces may not have a continuously burning pilot light. Section 110.5 and Section 110.2(d). Cooling Equipment Equipment Efficiency: All cooling equipment must meet the minimum efficiency requirements of Section 110.1 and Section 110.2(a) and the Appliance Efficiency 06 Regulations. Refrigerant Line Insulation: All refrigerant line insulation in split system air conditioners and heat pumps must meet the R -value and protection requirements of Section 07 150.0(j)2 and 3, and Section 150.0(m)9. 08 Condensing Unit Location: Condensing units shall not be placed within five (5) feet of a dryer vent outlet. See Section 150.0(h)3A. Sizing: Cooling load calculations must be done on portions of the building served by new cooling systems to prevent inadvertent undersizing or oversizing. See Section 09 150.0(h)1 and 2. Air Distribution System Ducts, Plenums and Fans Insulation: In all cases, unless ducts are enclosed entirely in directly conditioned space, the minimum duct insulation value is R-6. Note that higher values may be 30 required by the prescriptive or performance requirements. See Section 150.0(m)l. Registration Number: 217-A0185296A-M0100002A-0000 Registration Date/Time: 2017-06-01 22:15:52 HERS Provider: CaICERTS CA Building Energy Efficiency Standards - 2013 Residential Compliance Report Version: 2013 Rev 1.008 Report Generated: 2017-06-01 22:05:12 Schema Version: 2013.1.008 CERTIFICATE OF INSTALLATION CF2R-MCH-01-E Space Conditioning Systems, Ducts, and Fans (Page 7 of 8 K. Space Conditioning Systems, Ducts and Fans Mandatory Requirements and Additional Measures Note: Additional mandatory requirements from Section 150.0 that are not listed here may be applicable to some systems. These requirements maybe applicable to only newly installed equipment or portions of the system that are altered. Existing equipment may be exempt from these requirements. Connections and Closures: All installed air -distribution system ducts and plenums must be, sealed and insulated to meet the requirements of CMC Sections 601.0, 602.0, 603.0, 604.0, 605.0 and ANSI/SMACNA-006-2006: Supply -air and return -air ducts and plenums must be insulated to a minimum installed level of R-6.0 or 11 enclosed entirely in directly conditioned space as confirmed through field verification and diagnostic testing in accordance with the requirements of Reference Residential Appendix RA3.1.4.3.8. Heat Pump Thermostat 12 A thermostat shall be installed that meets the requirements of Section 110.2(b) and Section 110.2(c). 13 The thermostat shall be installed in accordance with the manufacturers published installation specifications 14 First stage of heating shall be assigned to heat pump heating. 15 1 Second stage back up heating shall be set to come on only when the indoor set temperature cannot be met. The responsible person signature on this compliance document affirms that all applicable requirements in this table have been met. Registration Number: 217-A0185296A-M0100002A-0000 Registration Date/Time: 2017-06-01 22:15:52 HERS Provider: CaICERTS CA Building Energy Efficiency Standards - 2013 Residential Compliance Report Version: 2013 Rev 1.008 Report Generated: 2017-06-01 22:05:12 Schema Version: 2013.1.008 CERTIFICATE OF INSTALLATION CF2R-MCH-02-E Space Conditioning Systems, Ducts, and Fans (Page 8 of 8 ) Documentation Author's Declaration Statement 1. 1 certify that this Certificate of Installation documentation is accurate and complete. Documentation Author Name: Documentation Author Signature: 1j Kevin Harry ' ,( `ASA O Company: Signature Date: Allied HERS Testing 2017-06-01 22:11:03 Address: CEA/ HERS Certification Identification (if applicable): 853 West L Street CC2006610 City/State/Zip: Phone: Benicia CA 94510 707-373-0196 Responsible Person's Declaration statement I certify the following under penalty of perjury, under the laws of the state of California: 1. The information provided on this Certificate of Installation is true and correct. 2. 1 am eligible under Division 3 of the Business and Professions Code in the applicable classification to accept responsibility for the system design, construction, or installation of features, materials, components, or manufactured devices for the scope of work identified on this Certificate of Installation, and attest to the declarations in this statement (responsible builder/installer), otherwise I am an authorized representative of the responsible builder/installer. 3. The constructed or installed features, materials, components or manufactured devices (the'. installation) identified on this Certificate of Installation conforms to all applicable codes and regulations, and the installation conforms to the requirements given on the plans and specifications approved by the enforcement agency. 4. 1 reviewed a copy of the Certificate of Compliance approved by the enforcement. agency that identifies the specific requirements for the scope of construction or installation identified on this Certificate of Installation, and I have ensured that the requirements that apply to the construction or installation have been met. S. I will ensure that a registered copy of this Certificate of Installation shall be posted, or made available with the building permit(s) issued for the building, and made available to the enforcement agency for all applicable inspections. I understand that a registered copy of this Certificate of Installation is required to be included with the documentation the builder provides to the building owner at occupancy. Responsible Builder/Installer Name: Responsible Builder/Installer Signature: Long Le Company Name: (Installing Subcontractor or General Contractor or Builder/Owner) Position With Company (Title): LOTUS AIR CARE Owner Address: CSLB License: 909 EAST HOMESTEAD ROAD 886016 City/State/Zip: Phone: Date Signed: SUNNYVALE CA 94087 408-892-6537 2017-06-01 22:15:52 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 o/ the information. Registration Number: 217-AO185296A-MO100002A-0000 Registration Date/Time: 2017-06-01 22:15:52 HERS Provider: CaICERTS CA Building Energy Efficiency Standards - 2013 Residential Compliance Report Version: 2013 Rev 1.008 Report Generated: 2017-06-01 22:05:12 Schema Version: 2013.1.008 CERTIFICATE OF INSTALLATION CF2R-MCH-20-H Duct Leakage Diagnostic Test (Page 1 of 3 ) Project Name: 10584 Johnson Ave Enforcement Agency: Cupertino City of Permit Number: B2016-1838 Dwelling Address: 10584 Johnson Ave City: Cupertino Zip Code: 95014 A. System Information 01 Space Conditioning System Identification or Name System 1 02 Space Conditioning System Location or Area Served Location 1 03 Building Type from CF -111 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 j Duct System Compliance Category New MCH -20a - Completely New Duct System B. Duct Leakage Diagnostic Test 01 Condenser Nominal Cooling Capacity (ton) 5 02 Heating Capacity (kBtu/h) 97 03 Conditioned Floor Area served by this HVAC system (ft2) 1984 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) 126 10 Actual duct leakage rate from leakage test measurement (cfm) 86 11 Compliance Statement: System passes leakage test Registration Number: 217-A0185296A-M2000002A-0000 Registration Date/Time: 2017-06-01 22:15:52 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.008 Report Generated: 2017-06-01 22:06:25 2013 Residential Compliance Schema Version: 2013.1.007 CERTIFICATE OF INSTALLATION CF2R-MCH-20-H Duct Leakage Diagnostic Test (Page 2 of 3 ) C. Additional Requirements for Compliance 01 System was tested in its normal operation condition. No temporary taping allowed. Outside air (OA) duct connections to the central forced air duct system shall not be sealed/taped off during duct leakage 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. 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. The responsible persons signature on this compliance document affirms that all applicable requirements in this table have been met. Registration Number: 217-A018S296A-M2000002A-0000 Registration Date/Time: 2017-06-01 22:15:52 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.008 Report Generated: 2017-06-01 22:06:25 2013 Residential Compliance Schema Version: 2013.1.007 CERTIFICATE OF INSTALLATION CF2R-MCH-20-H Duct Leakage Diagnostic Test (Page 3 of 3 ) Documentation Author's Declaration Statement 1. 1 certify that this Certificate of Installation documentation is accurate and complete. Documentation Author Name: Documentation Author Signature: Kevin Harry Company: Signature Date: 2017-06-01 22:11:03 Allied HERS Testing Address: CEA/ HERS Certification Identification (if applicable): 853 West L Street CC2006610 City/State/Zip: Phone: Benicia CA 94510 707-373-0196 Responsible Person's Declaration statement I certify the following under penalty of perjury, under the laws of the State of California: 1. The information provided on this Certificate of Installation is true and correct. 2. 1 am eligible under Division 3 of the Business and Professions Code in the applicable classification to accept responsibility for the system design, construction, or installation of features, materials, components, or manufactured devices for the scope of work identified on this Certificate of Installation and attest to the declarations in this statement (responsible builder/installer), otherwise I am an authorized representative of the responsible builder/installer. 3. The constructed or installed features, materials, components or manufactured devices (the installation) identified on this Certificate of Installation conforms to all applicable codes and regulations, and the installation conforms to the requirements given on the plans and specifications approved by the enforcement agency. 4. 1 understand that a HERS rater will check the installation to verify compliance, and that if such checking identifies defects; I am required to take corrective action at my expense. l understand that Energy Commission and HERS Provider representatives will also perform quality assurance checking of installations, including those approved as part of a sample group but not checked by a HERS rater, and if those installations fail to meet the requirements of such quality assurance checking, the required corrective action and additional checking/testing of other installations in that HERS sample group will be performed at my expense. 5. 1 reviewed a copy of the Certificate of Compliance approved by the enforcement agency that identifies the specific requirements for the scope of construction or installation identified on this Certificate of Installation, and I have ensured that the requirements that apply to the construction or installation have been met. 6. 1 will ensure that a registered copy of this Certificate of Installation shall be posted, or made available with the building permit(s) issued for the building, and made available to the enforcement agency for all applicable inspections. I understand that a registered copy of this Certificate of Installation is required to be included with the documentation the builder provides to the building owner at occupancy. Responsible Builder/Installer Name: Responsible Builder/Installer Signature: Long Le Zln Ze Company Name: (Installing Subcontractor or General Contractor or Position With Company (Title): Builder/Owner) Owner LOTUS AIR CARE Address: CSLB License: 909 EAST HOMESTEAD ROAD 886016 City/State/Zip: Phone: Date Signed: SUNNYVALE CA 94087 408-892-6537 2017-06-01 22:15:52 Third Party Quality Control Program (TPQCP) Status: Name of TPQCP (if applicable): Digitally signed by Ca10ERTS. 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: 217-A0185296A-M2000002A-0000 Registration Date/Time: 2017-06-01 22:15:52 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.008 Report Generated: 2017-06-01 22:06:25 2013 Residential Compliance Schema Version: 2013.1.007 CERTIFICATE OF INSTALLATION CF2R-MCH-23-H Space Conditioning System Airflow Rate (Page 1 of 3 ) Project Name: 10584 Johnson Ave Enforcement Agency: City of Cupertino Permit Number: 82016-1838 Dwelling Address: 10584 Johnson Ave City: Cupertino Zip Code: 95014 A. Ducted Cooling System Information 01 System Identification or Name System 1 02 System Location or Area Served Location 1 03 System Installation Type New 04 Nominal Cooling Capacity (tons) of Condenser 5 05 Condenser Speed Type Single Speed 06 Cooling System Zonal Control Type Not Zonal 07 Central Fan Integrated (CFI) Ventilation System Status Not a CFI system 08 System Bypass Duct Status No Bypass Duct 09 Date of System Airflow Rate Measurement 2017-05-31 10 Airflow Rate Protocol Utilized RA3.3 procedures for airflow rate measurement B. Hole for the placement of a Static Pressure Probe (HSPP), and Permanently Installed Static Pressure Probe (PSPP) in the Supply Plenum. Procedures for installing HSPP or PSPP are specified in RA3.3.1.1. 01 I Method Used to Demonstrate Compliance with theI HSPP installed and labeled consistent with Figure RA3.3-1 HSPP/PSPP Requirement C. Airflow Rate Measurement Apparatus and Procedure Information Instrument Specifications are given in RA3.3.1.1, and system airflow rate measurement apparatus information is given in RA3.3.2. 01 Airflow Rate Measurement Type used for this airflow rate Traditional Flow Capture Hood according to procedure in verification. RA3.3.3.1.4 02 Manufacturer of Airflow Measurement Apparatus Kanomax 03 Model number of Airflow Measurement Apparatus 6710-2 Certification Status of the Airflow Measurement Apparatus Certified by Manufacturer and listed on CEC Website at 04 Accuracy http://www.energy.ca.gov/title24/equipment_cert/ama_fas /index.html Registration Number: 217-A0185296A-M2300002A-0000 Registration Date/Time: 2017-06-0122:15:53 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.008 Report Generated: 2017-06-01 22:07:33 2013 Residential Compliance Schema Version: 2013.1.008 CERTIFICATE OF INSTALLATION CF2R-MCH-23-H Space Conditioning System Airflow Rate (Page 2 of 3 ) MCH -23a Forced Air System Airflow Rate Measurement - Newly Installed Non -Zoned Systems or Zoned Multi -Speed Compressor D. Forced Air System Airflow Rate Measurement The procedures for System Airflow Rate Verification are specified in Reference Residential Appendix RA3.3. 01 Required Minimum System Airflow Rate (cfm/ton) 350 02 Required Minimum System Airflow Target (cfm) 1750 03 Actual System Airflow Rate Measurement (cfm) 1755 04 Compliance Statement: System airflow rate complies E. Additional Requirements 01 Air filters that meet the applicable requirements of Standards Section 150.0(m)12 or 150.0(m)13 were properly installed in the system during system air flow rate measurement identified on this Certificate of Installation. The airflow rate measurement apparatus used to perform the airflow rate measurement identified on this Certificate of 02 Installation was calibrated in accordance with the apparatus manufacturer's specifications and conforms to the instrumentation specifications given in RA3.3.1. A visual inspection shall confirm that bypass ducts that deliver conditioned supply air directly to the space conditioning 03 system return duct airflow are not used on newly constructed zonally controlled systems unless the Performance Certificate of Compliance indicates an allowance for use of a bypass duct. When a bypass duct is accounted for on the Performance Certificate of Compliance, the airflow rate shall conform to the specifications listed on the Certificate of Compliance. 04 All registers were fully open during the diagnostic test. 05 System fan was set at maximum speed during the diagnostic test. 06 If fresh air duct is part of the HVAC system it was not closed during the diagnostic test. 07 Airflow rate and fan watt draw shall be simultaneous measurements when used to calculate the Fan Efficacy tested value. Multi -speed compressor space cooling systems or variable speed compressor systems shall verify air flow (cfm/ton) and fan 08 efficacy (Watt/cfm) with system operating in cooling mode at the maximum compressor speed and the maximum air handler fan speed. The responsible person's signature on this compliance document affirms that all applicable requirements in this table have been met. Registration Number: 217-A0185296A-M2300002A-0000 Registration Date/Time: 2017-06-01 22:15:53 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.008 Report Generated: 2017-06-01 22:07:33 2013 Residential Compliance Schema Version: 2013.1.008 CERTIFICATE OF INSTALLATION CF2R-MCH-23-H Space Conditioning System Airflow Rate (Page 3 of 3 ) Documentation Author's Declaration Statement 1. 1 certify that this Certificate of Installation documentation is accurate and complete. Documentation Author Name: Documentation Author Signature:,(1 Kevin Harry ' `aa4� Company: Signature Date: 2017-06-01 22:11:03 Allied HERS Testing Address: CEA/ HERS Certification Identification (if applicable): 853 West L Street CC2006610 City/State/Zip: Phone: Benicia CA 94510 707-373-0196 Responsible Person's Declaration statement I certify the following under penalty of perjury, under the laws of the State of California: 1. The information provided on this Certificate of Installation is true and correct. 2. 1 am eligible under Division 3 of the Business and Professions Code in the applicable classification to accept responsibility for the system design, construction, or installation of features, materials, components, or manufactured devices for the scope of work identified on this Certificate of Installation and attest to the declarations in this statement (responsible builder/installer), otherwise I am an authorized representative of the responsible builder/installer. 3. The constructed or installed features, materials, components or manufactured devices (the installation) identified on this Certificate of Installation conforms to all applicable codes and regulations, and the installation conforms to the requirements given on the plans and specifications approved by the enforcement agency. 4. 1 understand that a HERS rater will check the installation to verify compliance, and that if such checking identifies defects; I am required to take corrective action at my expense. I understand that Energy Commission and HERS Provider representatives will also perform quality assurance checking of installations, including those approved as part of a sample group but not checked by a HERS rater, and if those installations fail to meet the requirements of such quality assurance checking, the required corrective action and additional checking/testing of other installations in that HERS sample group will be performed at my expense. S. I reviewed a copy of the Certificate of Compliance approved by the enforcement agency that identifies the specific requirements for the scope of construction or installation identified on this Certificate of Installation, and I have ensured that the requirements that apply to the construction or installation have been met. 6. 1 will ensure that a registered copy of this Certificate of Installation shall be posted, or made available with the building permit(s) issued for the building, and made available to the enforcement agency for all applicable inspections. I understand that a registered copy of this Certificate of Installation is required to be included with the documentation the builder provides to the building owner at occupancy. Responsible Builder/Installer Name: Responsible Builder/Installer Signature: Long Le r�++ Company Name: (Installing Subcontractor or General Contractor or Position With Company (Title): Builder/Owner) Owner LOTUS AIR CARE Address: CSLB License: 909 EAST HOMESTEAD ROAD 886016 City/State/Zip: Phone: Date Signed: SUNNYVALE CA 94087 408-892-6537 2017-06-01 22:15:53 Third Party Quality Control Program (TPQCP) Status: Name of TPQCP (if applicable): 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: 217-A0185296A-M2300002A-0000 Registration Date/Time: 2017-06-01 22:15:53 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.008 Report Generated: 2017-06-01 22:07:33 2013 Residential Compliance Schema Version: 2013.1.008 CERTIFICATE OF INSTALLATION CF2R-MCH-22-H Space Conditioning System Fan Efficacy (Page 1 of 3 ) Project Name: 10584 Johnson Ave Enforcement Agency: City of Cupertino Permit Number: 82016-1838 Dwelling Address: 10584 Johnson Ave City: Cupertino Zip Code: 95014 A. Ducted Cooling System Information 01 System Identification or Name System 1 02 System Location or Area Served Location 1 03 System Installation Type New 04 Nominal Cooling Capacity (tons) of Condenser 5 05 Condenser Speed Type Single Speed 06 Cooling System Zonal Control Type Not Zonal 07 Central Fan Integrated (CFI) Ventilation System Status Not a CFI system 08 System Bypass Duct Status No Bypass Duct 09 Date of System Airflow Rate Measurement 2017-05-31 10 Airflow Rate Protocol utilized RA3.3 procedures for airflow rate measurement B. Fan Watt Measurement Apparatus and Procedure Information Instrument Specifications are given in RA3.3.1, and system fan watt measurement apparatus information is given in RA3.3.2.2. 01 1 Fan Watt Verification Device Used. Portable watt meter MCH -22a Forced Air System Fan Efficacy Measurement - Newly Installed Non -Zoned Systems or Zoned Multi -Speed Compressor C. Forced Air System Fan Efficacy Measurement The procedures for System Fan Watt Verification are specified in Reference Residential Appendix RA3.3 01 Actual Tested Watts 1010 02 Actual Tested Airflow from MCH -23 (cfm) 1755 03 Required Fan Efficacy (watts/cfm) 0.58 04 Actual Fan Efficacy (watts/cfm) 0.58 05 Compliance Statement: System fan efficacy complies Registration Number: 217-A0185296A-M2200002A-0000 Registration Date/Time: 2017-06-01 22:15:52 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.008 Report Generated: 2017-06-01 22:08:29 2013 Residential Compliance Schema Version: 0.52SDD CERTIFICATE OF INSTALLATION CF2R-MCH-22-H Space Conditioning System Fan Efficacy (Page 2 of 3 ) D. Additional Requirements 01 All registers were fully open during the diagnostic test. 02 System fan was set at maximum speed during the diagnostic test. 03 If fresh air duct is part of the HVAC system it was not closed during the diagnostic test. 04 Airflow rate and fan watt draw shall be simultaneous measurements when used to calculate the Fan Efficacy tested value. 05 Multi -speed compressor space cooling systems or variable speed compressor systems shall verify air flow (cfm/ton) and fan efficacy (Watt/cfm) with system operating in cooling mode at the maximum compressor speed and the maximum air handler fan speed. 06 Zoned cooling air distribution systems with single speed compressors shall meet both the airflow (cfm/ton) and fan efficacy (Watt/cfm) criteria in every zonal control mode. The responsible person's signature on this compliance document affirms that all applicable requirements in this table have been met. Registration Number: 217-A0185296A-M2200002A-0000 Registration Date/Time: 2017-06-0122:15:52 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.008 Report Generated: 2017-06-01 22:08:29 2013 Residential Compliance Schema Version: 0.52SDD CERTIFICATE OF INSTALLATION CF2R-MCH-22-H Space Conditioning System Fan Efficacy (Page 3 of 3 ) Documentation Author's Declaration Statement 1. 1 certify that this Certificate of Installation documentation is accurate and complete. Documentation Author Name: Documentation Author Signature: Kevin Harry ' `��y Company: Signature Date: 2017-06-01 22:11:04 Allied HERS Testing Address: CEA/ HERS Certification Identification (if applicable): 853 West L Street CC2006610 City/State/Zip: Phone: Benicia CA 94510 707-373-0196 Responsible Person's Declaration statement I certify the following under penalty of perjury, under the laws of the State of California: 1. The information provided on this Certificate of Installation is true and correct. 2. 1 am eligible under Division 3 of the Business and Professions Code in the applicable classification to accept responsibility for the system design, construction, or installation of features, materials, components, or manufactured devices for the scope of work identified on this Certificate of Installation and attest to the declarations in this statement (responsible builder/installer), otherwise I am an authorized representative of the responsible builder/installer. 3. The constructed or installed features, materials, components or manufactured devices (the installation) identified on this Certificate of Installation conforms to all applicable codes and regulations, and the installation conforms to the requirements given on the plans and specifications approved by the enforcement agency. 4. 1 understand that a HERS rater will check the installation to verify compliance, and that if such checking identifies defects; I am required to take corrective action at my expense. I understand that Energy Commission and HERS Provider representatives will also perform quality assurance checking of installations, including those approved as part of a sample group but not checked by a HERS rater, and if those installations fail to meet the requirements of such quality assurance checking, the required corrective action and additional checking/testing of other installations in that HERS sample group will be performed at my expense. S. I reviewed a copy of the Certificate of Compliance approved by the enforcement agency that identifies the specific requirements for the scope of construction or installation identified on this Certificate of Installation, and I have ensured that the requirements that apply to the construction or installation have been met. 6. 1 will ensure that a registered copy of this Certificate of Installation shall be posted, or made available with the building permit(s) issued for the building, and made available to the enforcement agency for all applicable inspections. I understand that a registered copy of this Certificate of Installation is required to be included with the documentation the builder provides to the building owner at occupancy. Responsible Builder/Installer Name: Responsible Builder/Installer Signature: Long Le -C.,on -Ce Company Name: (Installing Subcontractor or General Contractor or Position With Company (Title): Builder/Owner) Owner LOTUS AIR CARE Address: CSLB License: 909 EAST HOMESTEAD ROAD 886016 City/State/Zip: Phone: Date Signed: SUNNYVALE CA 94087 408-892-6537 2017-06-01 22:15:52 Third Party Quality Control Program (TPQCP) Status: Name of TPQCP (if applicable): 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: 217-A0185296A-M2200002A-0000 Registration Date/Time: 2017-06-01 22:15:52 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.008 Report Generated: 2017-06-01 22:08:29 2013 Residential Compliance Schema Version: 0.52SDD CERTIFICATE OF INSTALLATION CF2R-MCH-27-H Indoor Air Quality and Mechanical Ventilation (Page 1 of 5 ) Project Name: 10584 Johnson Ave Enforcement Agency: City of Cupertino Permit Number: 82016-1838 Dwelling Address: 10584 Johnson Ave City: Cupertino Zip Code: 95014 Title 24, Part 6, Section 150.0(0) Ventilation for Indoor Air Quality. All dwelling units shall meet the requirements of ANSI/ASHRAE Standard 62.2. Ventilation and Acceptable Indoor Air Quality in Low -Rise Residential Buildings. Equation and table numbering on this form corresponds to the numbering for that information in the published ANSI/SHRAE Standard 62.2-2010. A. Dwelling Mechanical Ventilation - General Information 01 Dwelling unit name 10584 Johnson Ave 02 Building Type Single family 03 Project scope Addition greater than 1,000 ft2 04 Total Conditioned Floor Area of Dwelling Unit (For addition projects the conditioned floor area equals existing area plus addition area. ) 1984 05 Number of bedrooms in dwelling unit (For addition projects the number of bedroomsequals the existing bedrooms plus addition bedrooms) 4 06 Ventilation Operation Schedule Continuous 07 Whole -Building Ventilation Rate Calculation Method Fan Ventilation Rate Method (4.1.1) 08 Whole Building Ventilation System Type Standalone - Exhaust MCH -27a - Continuous Ventilation Airflow - Fan Ventilation Rate Method B. Whole -Building Continuous Ventilation - Fan Ventilation Rate Method A mechanical supply system, exhaust system, or combination thereof shall provide whole -building ventilation with outdoor air each hour at no less than the rate in equation 4.1a. 01 Required Continuous Whole -Building Ventilation Rate 57 02 Installed Continuous Whole -Building Ventilation Rate 88 C. Compliance Statement 01 Building passes continuous whole -building ventilation rate test Registration Number: 217-A0185296A-M2700002A-0000 Registration Date/Time: 2017-06-01 22:15:53 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.008 Report Generated: 2017-06-01 22:11:07 2013 Residential Compliance Schema Version: 2013.1.008 CERTIFICATE OF INSTALLATION CF2R-MCH-27-H Indoor Air Quality and Mechanical Ventilation (Page 2 of 5 ) D. Local Mechanical Exhaust System - Fan selection and duct design criteria for compliance Local mechanical exhaust fans shall be installed in each kitchen and bathroom. Delivered local ventilation rates: • All local ventilation rates have been measured using a flow hood, flow grid, or other airflow measuring device and meet the requirements of 62.2 Tables 5.1 or 5.2. OR • The airflow rating at a pressure of 0.25 in. w.c. of a certified fan is assumed because the local ventilation system duct sizing meets the prescriptive requirements of 62.2 Table 5.3, or manufacturer's design criteria. Table 5.1 Intermittent Local Ventilation Exhaust Airflow Rates Application Airflow Notes Vented range hood (including Kitchen 100 cfm appliance -range hood combinations) required if exhaust fan flow is less than 5 ACH. Bathroom 50 cfm Table 5.2 Continuous Local Ventilation Exhaust Airflow Rates Application Airflow Notes Kitchen 5 ACH Based on Kitchen volume. Bathroom 20 cfm - Table 5.3 Prescriptive Duct Sizing Requirements Duct Type Flex Duct Smooth Duct Fan Rating cfm @ 0.25 50 80 100 125 50 80 100 125 in. w.g. Maximum Allowable Duct Length (ft) Diameter, Flex Duct Smooth Duct (in) 3 X X X X 5 X X X 4 70 3 X X 105 35 5 X 5 NL 70 35 20 NL 135 85 55 6 NL NL 125 95 NL NL NL 145 7and above NL NL NL NL NL NL NL NL This table assumes no elbows. Deduct 15 ft of allowable duct length for each turn, elbow, or fitting. Interpolation and extrapolation in 62.2 Table 5.3 is not allowed. For airflow values not listed, use the next higher value. This table is not applicable for airflow > 125 cfm. NL = no limit on duct length of this size. X = not allowed, any length of duct of this size with assumed turns, elbows, fittings will exceed the rated pressure drop. Registration Number: 217-A0185296A-M2700002A-0000 Registration Date/Time: 2017-06-0122:15:53 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.008 Report Generated: 2017-06-01 22:11:07 2013 Residential Compliance Schema Version: 2013.1.008 CERTIFICATE OF INSTALLATION CF2R-MCH-27-H Indoor Air Quality and Mechanical Ventilation (Page 3 of 5 ) E. Other Requirements The items listed below (6.1 through 6.8) correspond to the information given in ASHRAE 62.2 Section 6 Other Requirements. Refer also to Chapter 4.6 of the Residential Compliance Manual (Section 4.6.5) for information describing these Other Requirements. The signature of the Responsible Person in the declaration statement below certifies that the building complies with these requirements specified in ASHRAE 62.2 Section 6.1 through 6.9 if applicable. 6.1 Transfer Air Measures shall be taken to minimize air movement across envelope components to occupiable spaces from 01 garages, unconditioned crawl spaces, and unconditioned attics. Supply and balanced ventilation systems shall be designed and constructed to provide ventilation air directly from the outdoors. 6.2 Instructions and Labeling Information on the ventilation design and/or ventilation systems installed, instructions on their proper operation to meet the requirements of this standard, and instructions detailing any required maintenance 02 (similar to that provided for HVAC systems) shall be provided to the owner and the occupant of the dwelling unit. Controls shall be labeled as to their function (unless that function is obvious, such as toilet exhaust fan switches). See Chapter 13 of Guideline 242 for information on instructions and labeling. 03 6.3 Clothes Dryers Clothes dryers shall be exhausted directly to the outdoors 6.4 Combustion and solid -fuel burning appliances Combustion and solid -fuel burning appliances must be provided with adequate combustion and ventilation air and vented in accordance with manufacturer installation instructions, NFPA 54 ANSI Z223.1, National Fuel Gas Code, NEPA 31, Standard for the Installation of Oil -Burning Equipment, or NFPA 211, Standard for Chimneys, Fireplaces, Vents, and Solid -Fuel Burning Appliances, or other equivalent code acceptable to the building official. Where atmospherically vented combustion appliances or solid -fuel burning appliances are located 04 inside the pressure boundary, the total net exhaust flow of the two largest exhaust fans (not including a summer cooling fan intended to be operated only when windows or other air inlets are open) shall not exceed 15 cfm per100 ft2 (75 Lps per 100 m2) of occupiable space when in operation at full capacity. If the designed total net flow exceeds this limit, the net exhaust flow must be reduced by reducing the exhaust flow or providing compensating outdoor airflow. Atmospherically vented combustion appliances do not include direct -vent appliances 6.5 Garages When an occupiable space adjoins a garage, the design must prevent migration of contaminants to the adjoining occupiable space. Air seal the walls, ceilings, and floors that separate garages from occupiable space. To be 05 considered air sealed, all joints, seams, penetrations, openings between door assemblies and their respective jambs and framing, and other sources of air leakage through wall and ceiling assemblies separating the garage from the residence and its attic area shall be caulked, gasketed, weather stripped, wrapped, or otherwise sealed to limit air movement. Doors between garages and occupiable spaces shall be gasketed or made substantially airtight with weather stripping. 06 6.6 Ventilation Opening Area Spaces shall have ventilation openings as listed below. Such openings shall meet the requirements of Section 6.8 6.7 Minimum filtration Mechanical systems that supply air to an occupiable space through ductwork exceeding 10 ft (3 m) in length and through a thermal conditioning component, except evaporative coolers, shall be provided with a filter having a designated minimum efficiency of MERV 6, or better, when tested in accordance with ANSI ASHRAE Standard 07 52.2, Method of Testing General Ventilation Air -Cleaning Devices for Removal Efficiency by Particle Size, or a minimum Particle Size Efficiency of 50 percent in the 3.0-10 micrometer range in accordance with AHRI Standard 680, Performance Rating of Residential Air Filter Equipment. The system shall be designed such that all recirculated and mechanically supplied outdoor air is filtered before passing through the thermal conditioning components. The filter shall be located and installed in such a manner as to facilitate access and regular service by the owner. Registration Number: 217-A0185296A-M2700002A-0000 Registration Date/Time: 2017-06-01 22:15:53 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.008 Report Generated: 2017-06-01 22:11:07 2013 Residential Compliance Schema Version: 2013.1.008 CERTIFICATE OF INSTALLATION CF2R-MCH-27-H Indoor Air Quality and Mechanical Ventilation (Page 4 of 5 ) E. Other Requirements The items listed below (7.1 through 7.3) correspond to the information given in ASHRAE 62.2 Section 7 Air -Moving Equipment. 6.8 Air Inlets Air inlets that are part of the ventilation design shall be located a minimum of 10 ft (3 m) from known sources more detail. The signature of the Responsible Person in the declaration statement below certifies that the building complies with of contamination such as a stack, vent, exhaust hood, or vehicle exhaust. The intake shall be placed so that entering air 08 is not obstructed by snow, plantings, or other material. Forced air inlets shall be provided with rodent insect screens 01 (mesh not larger than half an inch). 6.9 Carbon Monoxide Detectors A carbon monoxide alarm shall be installed in each dwelling unit in accordance with NFPA 09 720, Standard for the Installation of Carbon Monoxide (CO) Detection and Warning Equipment 14, and shall be consistent with requirements of applicable laws, codes, and standards. The responsible persons signature on this compliance document affirms that all applicable requirements in this table have been met. F. Air Moving Equipment The items listed below (7.1 through 7.3) correspond to the information given in ASHRAE 62.2 Section 7 Air -Moving Equipment. Refer also to Chapter 4.6 of the Residential Compliance Manual (Section 4.6.6) for information describing these requirements in more detail. The signature of the Responsible Person in the declaration statement below certifies that the building complies with these requirements specified in ASHRAE 62.2 Section 7.1 through 7.3 if applicable. 7.1 Selection and Installation Ventilation devices and equipment shall be tested and listed in accordance with specific 01 standards. Installations of systems or equipment shall be carried out in accordance with manufacturers design requirements and installation instructions. 7.2 Sound Ratings for Fans Ventilation fans shall be rated for sound at no less than the minimum airflow rate required by this standard, as noted below. These sound ratings shall be at a minimum of 0.1 in. w.c. (25 Pa) static pressure. 7.2.1 02 Whole Building or Continuous Ventilation Fans. These fans shall be rated for sound at a maximum of 1.0 sone. 7.2.2 Intermittent Local Exhaust Fans. Fans used to comply with Section 5.2 shall be rated for sound at a maximum of 3 sone, unless their maximum rated airflow exceeds 400 cfm (200 L/s). (Some exceptions may apply.) 7.3 Multibranch Exhaust Ducting If more than one of the exhaust fans in a dwelling unit shares a common exhaust duct, 03 each fan shall be equipped with a back draft damper to prevent the recirculation of exhaust air from one room to another through the exhaust ducting system. The responsible persons signature on this compliance document affirms that all applicable requirements in this table have been met. G. Multifamily Buildings -Other Requirements This section does not apply to this project. Registration Number: 217-A0185296A-M2700002A-0000 Registration Date/Time: 2017-06-01 22:15:53 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.008 Report Generated: 2017-06-01 22:11:07 2013 Residential Compliance Schema Version: 2013.1.008 CERTIFICATE OF INSTALLATION CF2R-MCH-27-H Indoor Air Quality and Mechanical Ventilation (Page 5 of 5 ) Documentation Author's Declaration Statement 1. 1 certify that this Certificate of Installation documentation is accurate and complete. Documentation Author Name: Documentation Author Signature:y Kevin Harry Company: Signature Date: 2017-06-01 22:11:04 Allied HERS Testing Address: CEA/ HERS Certification Identification (if applicable): 853 West L Street CC2006610 City/State/Zip: Phone: Benicia CA 94510 707-373-0196 Responsible Person's Declaration statement I certify the following under penalty of perjury, under the laws of the State of California: 1. The information provided on this Certificate of Installation is true and correct. 2. 1 am eligible under Division 3 of the Business and Professions Code in the applicable classification to accept responsibility for the system design, construction, or installation of features, materials, components, or manufactured devices for the scope of work identified on this Certificate of Installation and attest to the declarations in this statement (responsible builder/installer), otherwise I am an authorized representative of the responsible builder/installer. 3. The constructed or installed features, materials, components or manufactured devices (the installation) identified on this Certificate of Installation conforms to all applicable codes and regulations, and the installation conforms to the requirements given on the plans and specifications approved by the enforcement agency. 4. 1 understand that a HERS rater will check the installation to verify compliance, and that if such checking identifies defects; I am required to take corrective action at my expense. I understand that Energy Commission and HERS Provider representatives will also perform: quality assurance checking of installations, including those approved as part of a sample group but not checked by a HERS rater, and if those installations fail to meet the requirements of such quality assurance checking, the required corrective action and additional checking/testing of other installations in that HERS sample group will be performed at my expense. 5. 1 reviewed a copy of the Certificate of Compliance approved by the enforcement agency that identifies the specific requirements for the scope of construction or installation identified on this Certificate of Installation, and I have ensured that the requirements that apply to the construction or installation have been met. 6. 1 will ensure that a registered copy of this Certificate of Installation shall be posted, or made available with the building permit(s) issued for the building, and made available to the enforcement agency for all applicable inspections. I understand that a registered copy of this Certificate of Installation is required to be included with the documentation the builder provides to the building owner at occupancy. Responsible Builder/Installer Name: Responsible Builder/Installer Signature: Long Le -++ on -Ce Company Name: (Installing Subcontractor or General Contractor or Position With Company (Title): Builder/Owner) Owner LOTUS AIR CARE Address: CSLB License: 909 EAST HOMESTEAD ROAD 886016 City/State/Zip: Phone: Date Signed: SUNNYVALE CA 94087 408-892-6537 2017-06-01 22:15:53 Third Party Quality Control Program (TPQCP) Status: Name of TPQCP (if applicable): Digitally signed by Ca10ERTS. 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: 217-A0185296A-M2700002A-0000 Registration Date/Time: 2017-06-01 22:15:53 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.008 Report Generated: 2017-06-01 22:11:07 2013 Residential Compliance Schema Version: 2013.1.008 Receipt: 117-120944 Product NOTI NOTI `iPoW Tender(Check) Check # Paid By 173 honggi hu 6/119/17 2:24 Pfd vaiguirre Name NOTICE NOTICE Regina Mcomruend ras Santa. Cperia County Cperk-Recorder (408) 299-5688 https://www.sccgov.org Document # # Pages Document # # Pacies PLEASE KEEP FOR REFERENCE Extended $31.00 23677557 3 $31.00 23677558 3 $62.00 $62.00