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14090197-DCITE' OF CUP El TINO BUILDING PERMIT IT BUILDING ADDRESS: 20387 GILLICK WAY CONTRACTOR: PERFECT HOMES PERMIT NO: 14090197 CONSTRUCTION CORP OWNER'S NAME: AMBATKAR PARIKSHIT AND GADEPALLI PA 382 LASSENPARK CIR DATE ISSUED: 11/07/2014 OWNER'S PHONE: 4086790580 SAN JOSE, CA 95136 PHONE NO: (408) 600 -8033 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL E] COMMERCIAL CONSTRUCT ONE STORE' ADDITIONS (499 SQ FT); License Class Lic. it f � INTERIOR REMODEL (1121 SQ FT); REMOVE AND ContractoIrm Date® � p RELOCATE FURNACE AND WATER HEATER; RELOCATE AND hereby that 1 am licensed under the provisions of Chapter 9 UPGRADE (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. revision 0- relocate washer /dryer in garage; expand (e) bedroom w/ laundy room I hereby affirm under penalty of perjury one of the following two declarations: space- issd ote 1/29/2015 1 have and will maintain a certificate of consent to self - insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the Sq. Ft Floor Area: Valuation: $215000 performance of the work for which this permit is issued. 1 have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this APN Number: 36936018.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT IT WORK IS NOT STARTED correct. I agree to comply with all city and county ordinances and state laws relating �� Il�� ISSUANCE OR to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save 180 AC'S O ]LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses ich may a rue against said City in consequence of the grantin f this mit. dditio ally, the applicant understands and will comply Issued by: Date: t ` with al on -poi t source regul ions per the Cupe ino Municipal Code, Section 9.18. RE- ROOFS: Signature Date All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. ❑ OWNER - BUILDER DECLARATION Signature of Applicant: Date: I hereby affirm that [ am exempt from the Contractor's License Law for one of the following trvo reasons: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) 1, as owner of the property, am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project (Sec.7044, Business & Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the declarations: Health & Safety Code, Section 25532(a) should 1 store or handle hazardous I have and will maintain a Certificate of Consent to self - insure for Worker's material. Additionally, should 1 use equipment or devices which emit hazardous Compensation, as provided for by Section 3700 of the Labor Code, for the air contaminants as defined by thc,5, Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance w h th Cu rtino unicipal Code, Chapter 9.12 and 1 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 the Health & Safety Code, cti s 255 5, 2 533, and 25 34. Owner or authorized agent: Date permit is issued. 1 certify that in the performance of the work for which this permit is issued, I shall 0 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 CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code, I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save ARCHITECT'S DECLARATION indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section Licensed Professional 9.18. Signature Date FS r �w5t.lpfJ� CUPERTINO ION COMMUNITY DEVELOPMENT DEPARTMENT ^ BUILDING DIVISION 10300 TORRE AVENUE e CUPERTINO, CA 95014 -3255 (408) 777 -3228 ^ FAX (408) 777 -3333 - building acupertino.org AnT)ITTCIN I I AT TFR ATIC)N / TI I I RFVT.QIC)N / T)FFFRRFT) a C)R IC:IN A T . PFR M IT f1 PROJECTADDRESS %% 6i VV vV APN# 4 -Q1� OWNER NAME pAQ,{ �C /��^i" 10`� 1 'U 0 r� ` D i7�OJ /p E-MAIL �WiY y�� -� `0 4 STREET ADDRESS - �� /1 f I ' p w j (/ CITY, STATE, ZI P _ , FAX CONTACT NAME �•f ^,' (^ L PT & n r r -y ` 6 ! E MAIL P A^ ' CA � S I 7J F E30) r N 1P3� STREET ADDRE S CITY, / ' ! ki ❑ OWNER ❑ OWNER - BUILDER 02 WNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGTNBER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME 1 L , �' ^ f1 LICE NU BER LICENSE TYPE BUS. COMPANY ME N E -MAIL FAX T -ET DDRESS CITY, STAT , Z ^,� PHONE _ 6 51 RTCPTI!i'iRQ1�$';:R BUS. LIC # C i NAM WrGi 2VI✓I ✓I E -M IL�M'n Axn r CN FA�' 2,;b -Cmr� STREET ADD S r 1 P(rf CITY, S TAA'TE,/V Z �� I A'T1W HQNE' 7 DESCRIPTION OF WORK tW V�1�i 1 YA ` �-Nq v EXISTING USE PROPOSED USE CONSTR. TYPE # STORIES / 9-27 V A 1 USE TYPE OCC. SQ.FT, VALUATION (S) EXISTG AREA jpO NEW FLOrpQJR AREA l Gl� DEMO ''. TOTAL AREA 1121 NETAREA BATHROOM REMODEL AREA KITCHEN REMODEL AREA OTHER RE OD A f V 1 PORCH AREA DECK AREA TOTAL DECKIPORC14 AREA GARAGE AR] ETACH ATTACH G: DWELLING UNITS: IS A SECOND UNIT []YES SECOND STORY ❑YES BEING ADDED? ❑ NO ADDITION? �NO PRE- APPLICATION ❑ YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YES TOTAL VALUATION: PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER EICHLER HOME? ❑ NO By my signature below, I certify to each of the following: I am th roperty owner or authorized ag o act property owner's behalf. I have read this application and the information I hav vided is correct. I haver the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating U ng construction aut i representatives of Cupertino to enter the above dentif d property f r inspec on purposes. Signature of Applicant/Agent: Date: SUPPLEMENTAL INFORMATION REQ I PLAN CHECK TYPE ROUTING SLIP ❑ OVER- THircoUNTER ❑ BUILDINGPLAN REVIEW _ New SFD or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ 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 1:1 MAJOR El SANITARY SEWER DISTRICT Submittal Of Building Permit application. ❑ ENVIRONMENTAL HEALTH BldgApp_1011.doc revised 06111111 I tom i li Li COMMUNITY DEVELOPMENT DEPARTMENT o BUILDING DIVISION 10300 TORRE AVENUE ^ CUPERTINO, CA 95014 -3255 ' CUPERTINO (408) 777 -3228 • FAX (408) 777 -3333 • building(8cupertino.orq ❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION / TI REVISION / DEFERRED OR PERMIT # PROJECT ADDRESS SOW APN9 o ®I fn �Ily��••v -' ^ 11Y PHONE 6� (g o STREETADDRESS CITY, STATE, ZIP FAX CONTACT NAME PHONE E -MAIL STREET ADDRESS CITY, STATE, ZIP -7 FAX ❑ OWNER ❑ OWNER - BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT O NAyQE N Ve4OMR & LICENSE TYPE BUS. LIC H C ANY NAME E -MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARCHITECT /ENGINEER NAME LICENSE NUMBER BUS. LIC 4 COMPANY NAME E -MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK ;♦//57jI �° /OII ® j�� n ®® A� ®� �� /� F�� lr/I Iri ®4WD ® ®i A EXISTING USE PROPOSED USE CONSTR. TYPE N STORIES USE TYPE OCC. SQFT. VALUATION (5) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA 7REMODELAREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH []ATTACH d DWELLING UNITS: IS A SECOND UNIT E] YES SECOND STORY [] YES BEING ADDED? F]NO ADDITION? F]NO PRE - APPLICATION ❑YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YES RECEI VEA, BY ` ' TOTAL VALUATION: PLANNING APPL 4 ❑ NO PLANNING APPROVAL LETTER EICHLER HOME? ❑ NO By my signature below, I certify to each of the following: I am the operty owner or authorized agent to act on the property oHaier's behalf. I have read this application and the information I ha vided is correct. I have re the Description of Work and verify it is accurate. I agree to comply with all applicable focal ordinances and state laws relating to it ing c nstruction. autho representatives of Cupertino to enter the abov - identified pro erty for ins on purposes. Signature of ApplicanUAgent: Da SUPPLEMENTAL INFORMATION itQ tlftt ` - ;?'� ,LAN CAECK TYPE r QUT.ING SLIP ., New SFD or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building OVER THE -COUNTER DWG PLAN REVIEW permit for new building. .i] EXPRESS - PLAnNING'PLAN REVIEW Commercial Bldgs: Provide a completed Hazardous Materials Disclosure Os srnNDARD ❑ PUBLICWORKS _ form if any Hazardous Materials are being used as part of this project. ❑ LARGE r z t FIRE DEPT t _ Copy of Planning Approval Letter or Meeting with Planning prior to '�I1'IAJOR 't' `❑ §ANITARYISEA'ERDISTRICT submittal of Building Permit application. o �. ❑. `ENVIRONMENTAL HEALTH BldgApp_2011.doc revised 06121111 d"Trrlr'Rr ?TTrl r1Tr T_Wb1 V1,rT[1TrT\T?T NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.). These fees are based on the preliminary information available and are only an estimate. Contact the Dept for adcdn7 info. FEE ITEMS (Fee Resolulion 11 -053 E f 7111131 FEE ESTIMATOR ` — l . B r1J U 1L I 1L'Li1LD0 1I 1 JLlG Vl Y D I VIS ION 1 °11url'. Non Chcc;; ADDRESS: 20387 gillick way DA'L'E: 01/29/2015 REVIEWED BY: Mendez 0 hours Plan Check, Hourly $143.00 ISTPLNCK APN: BP #: *VA LUATION: Iso *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex USE: Permit Fee: PIENTAMATION PERMIT TYPE: 1GENRES WORK revision #3- relocate washer/dryer in gara, e; expand a bedroom w/ laundy rooms ace SCOPE $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Ktv: �tclmini.ctr<.tfi�`c� F��e: (D Work Without Permit? 0 Yes Q No $0.00 Advanced Planning Fee: $0.00 Select a Non - Residential Q Building or Structure L 'Travel Doctanrrato 6(m fires: Stronp- Motion Fee: $0.00 Select an Administrative Item Bld,p Stds Commission Fee: $0.00 SUBTOTALS: $0.00 $143.00 TOTAL FEE, $143.00 NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.). These fees are based on the preliminary information available and are only an estimate. Contact the Dept for adcdn7 info. FEE ITEMS (Fee Resolulion 11 -053 E f 7111131 ,lfecl!. Plan Check 1 °11url'. Non Chcc;; MIISC ITEMS 41e�:h. Perr.!rt hc:e: Pcralil i•err 0 hours Plan Check, Hourly $143.00 ISTPLNCK fi!lrrI. 1 h:c•h. h" SP Othcv l'lr %rnh In�P $0.00 ,i.ldc l!. f sp. hrsh. File i.l,, !n ! l • -� -: NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.). These fees are based on the preliminary information available and are only an estimate. Contact the Dept for adcdn7 info. FEE ITEMS (Fee Resolulion 11 -053 E f 7111131 FEE QTYI F1ElE MIISC ITEMS Plan Check Fee: Hourly Only? 0 Yes (D No $0.00 0 hours Plan Check, Hourly $143.00 ISTPLNCK Suppl. PC Fee: E) Reg. Q OT Q,Q hrs $0.00 PME Plan Check: $0.00 = # Alternative Energy System $0.00 EV Charging Station Permit Fee: $0.00 Suppl. Insp. Fee:Q Reg. Q OT Q,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Ktv: �tclmini.ctr<.tfi�`c� F��e: (D Work Without Permit? 0 Yes Q No $0.00 Advanced Planning Fee: $0.00 Select a Non - Residential Q Building or Structure L 'Travel Doctanrrato 6(m fires: Stronp- Motion Fee: $0.00 Select an Administrative Item Bld,p Stds Commission Fee: $0.00 SUBTOTALS: $0.00 $143.00 TOTAL FEE, $143.00 Revised: 0110612015 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20387 GILLICK WAY CONTRACTOR: PERFECT HOMES PERMIT NO: 14090197 CONSTRUCTION CORP OWNER'S NAME: AMBATKAR PARIKSHIT AND GADEPALLI PA 382 LASSENPARK CIR DATE ISSUED: 11/07/2014 OWNER'S PHONE: 4086790580 SAN .LOSE, CA 95136 PHONE NO: (408) 600 -8033 ❑ LICENSED CONTRACTOR'S DEC TION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL E] �^ ^ CONSTRUCT ONE STORE' ADDITIONS (499 SQ FT); License Class Lie. # > V INTERIOR REMODEL (1121 SQ FT); REMOVE AND -Z _l RELOCATE FURNACE AND WATER HEATER; RELOCATE Contract Datc AND UPGRADE 1 hereby of that I am licen ed under the provisions of Chapter 9 REV # 2 - ADD ELECTRICAL, UPDATE TO BEDROOMS 2 - 4 (commencing with Section 7000) of Division 3 of the Business & Professions - ISSUED 1112/15 Code and that my license is in full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain a certificate of consent to self - insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the Sq. Ft Floor Area: Valuation: $215000 performance of the work for which this permit is issued. 1 have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this APN Number: 369360] 8.00 Occupancy Type: permit is issued. APPLICANT CERTIFICA'T'ION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct. 1 agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save 180 DAYS FROM LAST CALLED INSPECTION. 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 Issued by: Date: with all n(- poi urce regulations per the pertino Municipal Code, Section 9.18. ./ RE- ROOFS: Signature Date'( All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. ❑ OWNER - BUILDER DECLARATION Signature of Applicant: Date: I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) I, as owner of the property, am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project (Sec.7044, Business & Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the declarations: Health & Safety Code, Section 25532(a) should 1 store or handle hazardous I have and will maintain a Certificate of Consent to self - insure for Worker's material. Additionally, should 1 use equipment or devices which emit hazardous Compensation, as provided for by Section 3700 of the Labor Code, for the air contaminants as defined lal the Bay Area Air Quality Management District 1 performance of the work for which this permit is issued. will maintain compliance wit he C rtin034 ode, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, S ctions 55 , 2. Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized agent: Dater permit is issued. I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If, after making this certificate of exemption, I CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code, I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, ARCHITECT'S DECLARATION costs, and expenses which may accrue against said City in consequence of the 1 understand my plans shall be used as public records. granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section Licensed Professional 9.18, Signature Date CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20387 GILLICK WAY CONTRACTOR: PERFECT HOMES PERMIT NO: 14090197 CONSTRUCTION CORP OWNER'S NAME: AMBATKAR PARIKSHIT AND GADEPALLI PA 382 LASSENPARK CIR DATE ISSUED: 11/07/2014 OWNER'S PHONE: 4086790580 SAN JOSE, CA 95136 PHONE NO: (408) 600 -8033 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL ❑ c_, CONSTRUCT ONE STORY ADDITIONS (499 SQ FT); License Class y Lic. # r3, �Orj / INTERIOR REMODEL (1121 SQ FT); REMOVE AND RELOCATE Contractor (� IV . ate _ — FURNACE AND WATER HEATER; RELOCATE AND 1 hereby affirm that I am licensed under the provisions of Chapter 9 UPGRADE (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. 11/18/14 - REV # 1 - ADD ADDITIONAL 98 S.F. TO ENLARGE (E) FAMILY I hereby affirm under penalty of perjury one of the following two declarations: ROOM- ISSD 1/6/2015 1 have and will maintain a certificate of consent to self- insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the Sq. Ft Floor Area: Valuation: $215000 performance of the work for which this permit is issued. 1 have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this APN Number: 36936018.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that 1 have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct. 1 agree to comply with all city and county ordinances and state laws relating WL�III� ign PERMIT ISSUANCE OR building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save 180 DAY F OM LAST ALLED IN SP CT ON. indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the I granting of this permit. Additionally, the applicant understands and will comply Issued by: Date: with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. / RE- ROOFS: Signature A Date — — All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. ❑ OWNER - BUILDER DECLARATION Signature of Applicant: Date: I hereby affirm that 1 am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER 1, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) 1, as owner of the property, am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project (Sec. 7044, Business & Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the declarations: Health & Safety Code, Section 25532(a) should I store or handle hazardous I have and will maintain a Certificate of Consent to self- insure for Worker's material. Additionally, should 1 use equipment or devices which emit hazardous Compensation, as provided for by Section 3700 of the Labor Code, for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and 1 have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Sections 25505, 2553 , and 25534. Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized agent: Date:I DL_ S permit is issued. 1 certify that in the performance of the work for which this permit is issued, 1 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 CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code, l must 1 hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save ARCHITECT'S DECLARATION indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the 1 understand my plans shall be used as public records. granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section Licensed Professional 9.18. Signature Date • AF'PPLICATICIN COMMUNITY DEVELOPMENT DEPARTMENT o BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255 (408) 777 -3228 • FAX (408) 777 -3333 ^ building(d cupertino.org ❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/ Ti ❑ REVISION/ DEFERRED ORIGINAL PERMIT #! ( 0 at 31 A H PROJECT ADDRESS Z O LL([ (C ` W ^ PH NE �N I `5 EMAIL 11WNENA PA�<HIT M3��c� 0°tdc emd °l I %1 M0.) ° L,pyyy S STREET ADDRESS CITY, STATE, LIP FAX 20 Lk_W< w of E_ 1 I ca (A- 0t Su I -i CONTACT NAME PHONE E -MAIL STREET ADDRESS CITY, STATE, ZIP FAX ❑ OWNER ❑ OWNER- BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTR.AC'iOR NAME LICENSE NUMBER LICENSE TYPE BUS. LIC # ToM F COMPANY NAME E -MAIL FAX rA r o.J ! 6Lu�Tl STREET ADDRESS CITY, STATE, ZIP PHONE A TTECT/EnnNGINEER NAME LICENSE NUMBER BUS. LIC # �CH A9_ HPA=0 COMPANY NAME E -MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK N WI E w P41 E W T H ov T- F m AL_ b SH EF_ T Ro CtL ArfJ'D 9 f A (fQ E j EXISTINGUSE PROPOSED USE CONSTR. TYPE #STORIES USE TYPE OCC. SQ.FT. VALUATION ($) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECKiPORCH AREA GARAGE AREA: DETACH ❑ ATTACH #DWELLING UNITS: IS A SECOND UNIT ❑YES SECONDSTORY ❑YES BEING ADDED? []NO ADDITION? ❑NO PRE- APPLICATION ❑YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑YES IS THE B ^ IVED BY: TOTAL VALUATION: PLANNING APPL # []NO PLANNING APPROVAL LETTER HOME? ❑ NO By my signature below, l certify to each of the following: I am the property ow au orizcd agent to roperty owner's behalf. 1 have read this application and the information I have provided is correct. I have read the Description of Work an Is accurate. I agree to comply with all applicable local ordinances and state laws relating o ildi con truction. I authorize representatives of Cupertino to enter the above - identified property for inspection purposes. Signature ' 1 '" ` � Date: 1/ 12— 2-01 S of Applicant/Agent: SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECK TYPE ROUTING SLIP ❑ ovER•THE- COUNTER ❑ BUILDING PLAN REVIEW _ New SFD or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ EXPRESS ❑ PLANNINC PLAN REVIEW _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ 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 ❑ MAJOR ❑ SANITARY SEWER DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH BldgApp_201 I. doe revised 06121111 FM'_7' FEE ESTIMATOR - BUILDING DffVff SION CITY OF CUP E]f8TINO ADDRESS: 20387 GILLICK WAY DATE: 01112/2015 REVIEWED BY: MELISSA 3u'rvV - .0 APN: 369 36 018 BP #: 14090197 'VALUATION: Iso *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY USE: SFD or Duplex PENTAMATION PERMIT TYPE: 1GENRES d WORK REV # 2 -ADD ELECTRICAL UPDATE TO BEDROOMS 2 - 4 -ISSUED 1/12/15 SCOPE NOTE: This estimate does not includefees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District. etc-). These fees are based on the oreliminary information available and are only an estimate. Contact the Dent for addh 7 info. ]FEE ITEMS (Fee Resolution 11 -053 Elf 711113) IA.!cb, P1oi? ('heck Pfiwlh. Plur� L`'':r;ci Elec. Eech, v llerw ;l Fee' Phonb. Pertn;l Fee: "lec Perim" l er rJ;:�er �eeir, Insh. EJ (lttrer Plualb Insrr •r��ri�. In., /�. I c =c: P/ewb. Insp. J E'ee NOTE: This estimate does not includefees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District. etc-). These fees are based on the oreliminary information available and are only an estimate. Contact the Dent for addh 7 info. ]FEE ITEMS (Fee Resolution 11 -053 Elf 711113) ]FEE QTY /]FEE MISC ITEMS Plan Check Fee: Hourly Only? C) Yes (D No $0.00 0 hours Plan Check, Hourly $143.00 1STPLNCK Suppl. PC Fee: Q Reg. 0 OT — 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: Hourly Only? (D Yes Q No $0.00 Suppl. Insp. Fee:Q Reg. Q OT 0,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 ( ",oni71'uct',on K X: 'fil blia tn"'iivc Fee: 0 Work Without Permit? 0 Yes E) No $0.00 Advanced Planning .Fee: $0.00 Select a Non- Residential G Building or Structure 0 d Strom Motion Fee: $0.00 1.0 hrs Inspections $143.00 IsTrNSP Inspection, Hourly Bldg Stds Commission Fee: $0.00 SU BTOTAILS: $0.00 $286.00 T ®TAIJ FEE: $286.00 Revised: 01/06/2015 CUPERTINO CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT ^ BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255 0 1 (408) 777 -3228 • FAX (408) 777 -3333 • building(ocupertino.org []NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION / TI REVISION / DEFERRED ORIGINAL PERMIT #_J W49C f PROJECT ADDRESS vAL/G� A ° APN # � r � ! w — /e^y %S � OWNER NAME i 14q, y V19 � AIL STREET ADDRESS CITY– STTATTE ZIP FAX CONTACT NAMEt/ 11 }}1n �r ` ]�s MAI I d dl STRF�gffE1� A &/P ! . r CITY,AW , ,P�lbt_ � 'I S1425 FIAXY� ❑ OWNER ❑ OWNER- BUILDER ❑ OUTER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSENUMBER LICENSETYPE BUS. LIC9 COMPANY NAME E -MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE NAME �GI (gam I I �..„ ,,, 1(, LICENSE NUMBER BUS. LIC # Y NAME W�F'1 M6 l�1 b p IUI*16 E -MAIL �vvckteA 0 /M a *q . 2 3,12P °04r_" STREET DREM /EL /S�CRIP(T/IONOF CITY E, 41P A ��^I P 0 3,2.' s� D WORK EXISTING USE RIF W 7, e ?) 1 ` PROPOSED USE CONSTR VO-7, TYPE V0 k STORIES # 7 USE TYPE OCC. SQ.FT. VALUATION (S) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH []ATTACH # DWELLING UNITS: IS A SECOND UNIT ❑ YES SECOND STORY E] YES BEING ADDED! ❑NO ADDITION? ❑NO PRE - APPLICATION ❑ YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YES OTAL VALUATION: PLANNING APPLk ❑NO PLANNING APPROVALLETTER EICHLEF HOME? NO By my signature below, I certify to each of the following: I am th property owner or authorized agent to on t erty owner's behalf. I have read this application and the information I h provided is correct. 1 have d the Description of Work and verify accurate. 1 agree to comply with all applicable local ordinances and state laws relati o ild g const c On. a r ze represen tives of Cupertino to enter the above -idpep ifretdjpr for inspection purposes. Signature of Applicant/Agent: Date: SUPPLEMENTAL INFORMATION RE D ikLL sq I '" UTING �S d ' New SFD or Multifamily dwellings: Apply for demolition permit for0 r 'rr HECOTJNTER BiJILDINGPLANREVIEW existing building(s). Demolition permit is required prior to issuance of building u„OVER _ a ,fir 1 cFq r x "�zr permit for new building. t .?y e C�x EXPRESS' d ?` 4 ❑PLANI,INGPLAN1tEVIEW 7 _ Bldgs: Provide a completed Hazardous Materials Disclosure i.�rrrT t� �� sTAnnA l z* ` ❑PUBiICiVORKS$� `� r _Commercial form if any Hazardous Materials are being used as part of this project. Qrb r ©�LARGErti� �' � ,� ya�,� ❑�FIREDEPT s,�es�' 9 "'4 s< k; Copy of Planning Approval Letter or Meeting with Planning prior to MAJOR + �a �`'�`}:.� �'`� �� ❑ SEli ER DISTRICT � *. submittal of Building Permit application. -'❑� �,� + rc s �� SAI\ITARX . i+iN jai a - tic �a 80` . 0 =.:: "ENVIRONMENTALwHEALTH_.�N . B1dgApp_2011.doc revised 06/11/11 CITY OF cCU]FERTMO FEE ]ESTIMATOR — BUILDING DIVISION ImADDRESS: 20387 GILLICK WAY DATE: 11/18/2014 REVIEWED BY: MELISSA APN: 369 36 018 BP #: 14090197 "VALIDATION: Iso PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY Commercial Building USE: Odle:. LICC'. Insp. LJ PENTAMATION PERMIT TYPE: WORK 11/18/14 - REV # 1 - ADD ADDITIONAL 98 S.F. TO ENLARGE E FAMILY ROOM SCOPE $0.00 NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.). These fees are based on the preliminary information available and are onlv an estimate. Contact the Dept for addn'l info. FEE ITEMS (Fee Resolution 11 -053 Ef : 711113) ? ech. Plarr C'hv�c'k Plair; ('itcoA E1'e" -'lire OI&C/f llech, I'2rntit hix>� F'lurtb. Ptrr?3ir I;�,i" hi�r. R�rmr? h`er'� Qlik6' ?' r<''If!lT117 tYi,St> Odle:. LICC'. Insp. LJ Alacff. i isp. I °ic: 11171w;). laxp. $0.00 NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.). These fees are based on the preliminary information available and are onlv an estimate. Contact the Dept for addn'l info. FEE ITEMS (Fee Resolution 11 -053 Ef : 711113) ]FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 Select a Misc Bldg/Structure or Element of a Building Suppl. PC Fee: E) Reg. 0 OT 0,0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee:Q Reg. Q OT 0,0 hrs $0.00 PN1E Unit Fee: $0.00 PME Permit Fee: $0.00 (?)nz fruc tial. TOO: 4.f.hni�u:ct� °fxtiv +� h. E) Work Without Permit? 0 Yes E) No $0.00 Advanced Planning Fee. $0.00 Select a Non - Residential Building or Structure G a Yiuvei l ?nc rv�rae�t�trtlir�rr Fees: Strom Motion Fee: $0.00 F_71] # $859.00 Revisions IREVSFDWL SFDWL Bldg* Stds Commission Fee: $0.00 SUBTOTALS: $0.00 $859.00 TOTAL ]FEE: 1 $859.00 Revised: 10/0112014 00 o ,- LL o a 0 m R LL a U tl\� V (O \` O N E C m . (1 � O o � m E C � � C0 0 E O Z G d O A LL F- 7 w m 2 a .2 V C cn N A c c m Q C � =p N m C = � O CL cn 'C N � N 0 Q E _ � O v m m � • v a` U VED 2015 V) w w U U v >o w 2 U) 0 _m OD 10 Lb N G1 E Y O c 0 0 N d ac m a 00 00 00 0 H O N m a0. m N c v 0 t a a s d' V1 .4 0 O s LL u C 0 0 O a 0 ac 00 C. O ai w °o m O CD O O N 00 O N 0 CD N N o n 0 Q u C ai N •U w E Z w c o c m N .O CO bb a u `0 v a 0 O V E a 0 co c W o co O Cl N o O N S co C a 0 O N � O 0 a O N a a N c0 w c U W co 0 c a 0 .y c m E a O 0 O� co o O t7 a O l! 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' U w U Z O LL w a J H z W cu C a Q W C � U -0 N � m J a u c O CD o U C- rn 'C d O N w ci O E U c Z O u- v w ° Lv 0 a v U C W U m � U CA Lo O Ln r-I 0 N Y L: d O d l7 a •C o LU n w d 2 Ct N O of m co N O N 6 E c to d 8 O O O 0 O U m 0 v d d E Z O txo w V a n Ln 0 N )o 0 0 LL O 7 0 0. d z C a E 0 V io c d a d w 0 v v c c cu c LU to v m v C C M C) C C) co w o O Z A C U w 7 Md 3 Z N C j C 0 c�ncC °•-•- S C S; LL CO �CO N CO tilt e} Q) w N :sr W UJ � %+ m h \� Co W •C N co �•C N 'C N \-W = N \\ N N \ N V 0) C N •C co O�-•C Z J a CN 0 x mN C �N O)fn •C 010. 'p C C pp k mN� m(V O)n = Cl) > CD IC dU Tz p °'w � O C�j;5 a 8 o U p •° �o �C hn O o c � t y _ (D (� O U m a ULL cp _C N h N UL� h cp C h O N C d \ Cty LLt LL \ y CL� UJ LL \ d p) LL vJ \ d O) O d \ CLL lL= U- \ v) CL� LL \ C v-) lL \ d O) C4 d= d C .0 'J O O j .� 'J d C .J a 'J _ N LL LL U cU'W I^ 0 0 cU�� 0 0 U�Q°' LO LOU CU W d CUO 0 0 c0�02 y 1 N Z +- E I I o � Z w � CO to d d 7 A O. 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N ° m .1 4.1 M L y w w G O > a) a p u m a t W a m w v = CLJ O 4 G O R N 01 v 4 � o 3 N io °c w c c ° rn cz Q) N v rz n U Ln o � a ° N N tD lD y y O C.71 E cc y `aj U o ' C o ° C w 0 a1 cz 0 U ^ O y tla n cc U Ql y W O U ` C a 10 O Q C EE a u a � c w CL 8 Q ° r L � °O j 0 °o ON y O m °O v '01 � m c O � Q V v c ac N lyJ N U U m v w U � •o E a � c c: Z w co c ea -y ° C t H 7 m o = U O m 0 y O C U y m E C 7 O U ,-o .m U � m c L m a o E � U v C c m a cl g m m I EO a L J Uv o i I y 1' — N c O m O CL ° 0 m Cl a C N E 2 o .L m n E a 0 a- m c -0 0) � E; m C M� = L m y wa c Lf) O to t0 c 0 0) � 0 w� U o t N E S 3 15 N N 00 cmi rn o C .� DO C m QO y O% N O .CCD a -0 U y y 'y N � 00 111 1*- O m U T m N L c u CD -o c a1 N O I w M N :2 m •n ro 3 c c 0 M m m v O 0 0 t° V 0p N ° O m 0 0 o' in `~ U 0- o m W o N J c a rt o a m Q m m E o U_ O w U c r c 1 CD 1 aU api N N m y C m n c r m E m E d p y E _ m m y o v U -c c m c m occ o m y 0.- N U N N C p U N U � m .LO. N E O p N a1 y y w c S a w n w U �.co C r mm Q m LLJ c° Z' no E Q p C° N D o >> a E a F- m m y O v c _O 2 �m� ma 5, m y m C C Q m 'n O. N a° c J W o 5 Cl) o c 'b -.R �a m a. a U W N N CD V C Q. o .`O d .? DI N O m p m U C O --* N Z y c m a; C. rn O m m m C 00 O r Z O) c m Z > Q `y p N V Q N L c 7 �, U vi 0) N c m ` p m In rn z 0 o ¢ 0 c m U w a m�, 3 rn .o cD y o o c Q a c m a ti -° 'CU `-° 'r- pm m m U H Y° m m E o ti M ° O N m ° rnm E a' a1 = = c c: m n N N Z w z C m T U X m� Z m 0)c p L m U Q. i 3 N U N o ° m E n (` o w c m O t m t N O „u M Z d c a a to c O U Q a v U1 v 04 ri U Q N U (� U C F � = W 00 U O V r 00 U ri m to U O U 11 m v ° .t_. 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E a ' m u O is io p v O m u u y m d •° ` v �v'Y L 3 ;y^• mm a0+ a`, v W Obi C a w n E aJ � L � C C V m E a) _ o o m 3 °. .G O m� Ln o CO u a c N v o 0 La w 'o •;a c �= c a a U u Ln a it o fo a a, c f0 � U C io 2 o a a, v .a -o c. t; :g is > u_ - — m s T mV a," o' . f0 N ,w.n :N o m u a E a, m c O Y 3 V .O t > a m O a h m a, m u a, c U- U a c w o O ti n y v g E N a y IA m a, �a j '� N C N C u 0 u u s O W p v .o u L 0 0_ v 7 . u C— = a U m .a = 'a u c f�0 b' v$ C p E v y> o N a o y 3 0; 8, -(,u ° m a a -° :2 � E m C C O O V c o o w m > > - w o cO a o m C O c ° m o n u o y o Gl '3 C ° a, y o , ` u° E u ° o Z C N 7_ C C `, w h ry 0 m a, L a, m t+ 'm E aJ �Ni1 aL+ m 00 a Q U O N 8+ al u C o .N % N o c -('u v u O C b+ 1A C CO w n E o 7 W u N N O a, ea � s U Z� Y w w t w" y >.. c C t`o O G Y vY �'Q °v ° V o-0 l) `O N i y a, w u y ° o Z N 0 u OZ m c 5° yc v 7 a c 0 -o o `w 7 o u O U >_ j m I y a, m i m> v E °D O p c opmc E O u E S a n N VI V 3 h L Z Z O V O U —° 7° a o o 5 c a a a u a 0 y co N m Z c 0 r s +�' o c U v m s m E a v y o �a o o w c c ° U U m O tw L V1 Y oc . i n c o °a c .^_ c• c O 3 n o o _0 3 m v v h- _C w Y °c r I Ln m a.+ ¢ 7 Qd 01 o v E E L a :°. > 2 n v 7 "' � Qa. Ol s o Z O Z Q A •� 3 o L m 0 7 L C_ C 3 a nn c O EY io C V1 N, w Y a, C 2 V1 w Ln O 01 u a` 7 c U LL Q� N m O O w N N 7 c U O () — E Q N IA M v 1!1 O~ p_ LL N V1 O 7 E E a, a E E°C •pN TZ 2 m uLn V uval a° u°a ¢ � H ua- ¢m W U U a aJ a :a 0 Vl N � fV w V � U 0 a O 0 0 0 N S 'O v I W c v Q t O ccn W I i ; I , C i N 0 O O LO 0 N a p ry 0 a, O Ln E v N 00 cu m C m G O p 0 c O a, E v 0 a Ln, 0 O 9 Q O 0 O 14 O u n O Q v N L E 7 2 ao c m Q) ❑C CERTIFICATE OF INSTALLATION CF2R- ENV -02 -E Envelope Air Sealing - ENV -02 (Page 1 of 5 ) Project Name: GADEPALLI Enforcement Agency: City of Cupertino Permit Number: 14090197 Dwelling Address: 20387 GILLICK WAY City: Cupertino Zip Code: 95014 Note: The Energy Efficiency Standards Section 110.7 requires that "all joints, penetrations and other openings in the building envelope that are potential sources of air leakage shall be caulked, gasketed, weather stripped, or otherwise sealed to limit infiltration and exfiltration. " ASHRAE 62.2 Addendum.j section 8.4 "measures shall be taken to minimize air movement across envelope_ components separating.drvelling; units;: including''Sea"'ng penetrations in the common walls, ceilings, and floors of each unit and by sealing vertical chases adjacent to the units." The requirements below are for newly constructed spaces, additions and alterations to existing assemblies. In areas where Spray Foam (SPF) insulation is used, the SPF can be considered the air barrier. Rigid board insulation is also-an air barrier as long as ;infiltration cannot bypass the product. All other forms of insulation are not considered an air barrier and cannot be used as such. A. Raised Floor Air Barrier 01 All gaps in the raised floor are sealed. 02 All chases sealed at floor level using a hard cover and the hard cover is sealed. 03 All plumbing and electrical wires that penetrate the floor are sealed. The responsible person's signature on this compliance document affirms that all APPLICABLE requirements have been met. B. Wall /Knee Wall Air Barrier I I 01 All penetrations through the exterior wall are sealed to provide an air -tight envelope to unconditioned spaces such as the outdoors, attic, garage and crawl space. 02 Exterior wall air barrier is sealed at the top plate and bottom plate. 03 All penetrations through the exterior sheathing to unconditioned space such as electrical boxes including knockouts, plumbing and lineset are sealed 04 All openings in the top and bottom plate, including all interior and exterior walls, to unconditioned space are sealed. 05 Exterior bottom plates( all stories) are sealed to the floor. 06 All gaps around windows and doors are sealed. Sealant used must be per window manufacturer specifications. 07 Rim joist gaps /openings are fully sealed. Add blocking above walls (between the top plate and sheathing above) separating garage and or porch from the conditioned space. 08 Exhaust ducts running between conditioned floors to the exterior walls shall have a damper at the exterior wall. A solid air barrier is installed, from floor to ceiling, on interior walls before tub, shower, and fireplace enclosures are 09 installed against exterior walls. Insure insulation is installed behind the tub, shower and fireplace enclosure. 10 Knee walls have solid and sealed blocking at the bottom, top, left side and right side of the knee wall. Registration Number: 214- A0101976C- E0200001A -0000 Registration Date /Time: 2015 -06 -30 09:29:33 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2014 -05 -08 Report Generated: 2015 -06 -30 09:21:20 2013 Residential Compliance Schema Version: 0.553SDD CERTIFICATE OF INSTALLATION CFZR- ENV -02 -E Envelope Air Sealing - ENV -02 (Page 2 of 5 ) B. Wall /Knee Wall Air Barrier 11 All doors weatherstriped including between garage and home, including interior HVAC closets that are not conditioned. 12 Exhaust ducts for fans and dryer that run through chases include a damper where they exit the building. The responsible person's signature on this compliance document affirms that all APPLICABLE requirements have been met. C. Ceiling /Attic Air Barrier t 01' - All penetrations through the ceiling are sealed to provide an airtight envelope to the attic. 02 All chases are covered with hard covers and sealed to framing, including chases for fireplace, HVAC ducts, exhaust ducts, etc. 03 Double walls that open to attic are covered with an air barrier and sealed to the framing, 04 Electrical boxes, smoke detectors, can lights sealed to ceiling. 05 All openings and penetrations in the top plate to nonconditioned space in interior and exterior walls are sealed. 06 Attic access gasketed. The responsible person's signature on this compliance document affirms that all APPLICABLE requirements have been met. D. Walls For Attached Porch, Attic, Double Wall i 01 All walls that separate conditioned and unconditioned space includes a continuous air barrier on the interior and exterior wall. 02 An exterior wall air barrier is required at the intersection of the porch and exterior wall when there is conditioned space on the other side. The exterior wall includes an air barrier where the attic attaches to the conditioned space. 03 Air barrier installed on all kneewalls on the nonconditioned side of the assembly. The responsible person's signature on this compliance document affirms that all APPLICABLE requirements have been met. Registration Number: 214- A0101976C- E0200001A -0000 CA Building Energy Efficiency Standards 2013 Residential Compliance Registration Date /Time: 2015 -06 -30 09:29:33 HERS Provider: CalCERTS Report Version: 2014 -05 -08 Report Generated: 2015 -06 -30 09:21:20 Schema Version: 0.553SDD CERTIFICATE OF INSTALLATION CF2R- ENV-02 -E Envelope Air Sealing - ENV -02 (Page 3 of 5 ) E. Conditioned Space Above or Adjacent to Garage Air Barrier 01 If there is a conditioned space above the garage choose option 1 or 2 for proper air sealing. 02 Option 1- Insulation placed on garage ceiling. Walls separating garage from the conditioned space shall be blocked and 03 sealed. This is to stop air movement from the garage into the living space. Seal the band joist at the perimeter of the 02 condition space above a garage so that the space under the conditioned floor is air tight to the outside. 04 Option 2 - Insulation placed under floor of conditioned space. Walls separating garage from the conditioned space shall be The responsible person's signature on this compliance document affirms that all APPLICABLE requirements have been met. blocked and,sealed. This'is to'stop air movement from the garage into the living space. Seal all subfloor seams and penetrations between the garage and adjacent conditioned space. the responsible person's signature on this compliance document affirms that all APPLICABLE requirements have been met. F. Cantilevered Floor Air Barrier 01 Airtight blocking is installed between joists where the wall rim joist would have been located in the absence of a cantilever, 02 Exterior sheathing is installed to the bottom of the cantilever so that there is a continuous air and weather barrier for the 03 cantilever. 03 Any gaps, cracks or penetrations in the air barrier of the cantilever are sealed. Can lights in the cantilever must be IC and AT 04 rated and properly sealed to sheathing. The responsible person's signature on this compliance document affirms that all APPLICABLE requirements have been met. G. Multifamily Air Barrier 01 ' Multifamily buildings must meet all air sealing requirements listed above. 02 Each dwelling unit must be air sealed to stop air movement from one unit to another. 03 Floor and ceiling of each dwelling unit - all penetrations through the floor and ceiling of each unit are sealed, including electric and gas utilities, water pipes, drain pipes, fire protection service pipes, and communication wiring. 04 Elevator penthouse, mechanical penthouse, stairwell doors, roof access hatch, and plumbing stacks are all sealed to reduce air transfer from attached spaces. Common Walls - the bottom plate between units is sealed to the subfloor. All penetrations in the common walls are sealed 05 including electrical boxes, wiring and plumbing penetrations. Perpendicular interior walls that open into the common walls are sealed. 06 Vertical Chases - all penetrations through the chase must be sealed to stop air movement through the chase to the surrounding spaces. Vertical Chases - Where each floor /ceiling meets the chase this area must be sealed to the floor and ceiling of each unit to 07 stop air movement up and around the exterior of the chase due to stack effect. Common hallways - penetrations between dwelling units and common hallways are sealed, Doors to dwelling units shall be 08 gasketed. Registration Number: 214- A0101976C- E0200001A -0000 Registration Date /Time: 2015 -06 -30 09:29:33 HERS Provider: CalCERTS CA Building Energy Efficiency Standards Report Version: 2014 -05 -08 Report Generated: 2015 -06 -30 09:21:20 2013 Residential Compliance Schema Version: 0.553SDD CERTIFICATE OF INSTALLATION CF2R- ENV -02 -E Envelope Air Sealing - ENV -02 (Page 4 of 5 ) G. Multifamily Air Barrier The responsible person's signature on this compliance document affirms that all APPLICABLE requirements have been met. Registration Number: 214- A0101976C- E0200001A -0000 Registration Date /Time: 2015 -06 -30 09:29:33 HERS Provider: CalCERTS CA Building Energy Efficiency Standards Report Version: 2014 -05 -08 Report Generated: 2015 -06 -30 09:21:20 2013 Residential Compliance Schema Version: 0.553SDD CERTIFICATE OF INSTALLATION CF2R- ENV -02 -E Envelope Air Sealing - ENV -02 (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: �ii�i�lf/ Tom Tuan Nguyen P�fi Company: Signature Date: PERFECT HOMES CONSTRUCTION 2015 -06 -30 09:29:33 Address: j CEA/ HERS Certification Identification (if applicable): 382 LASSENPARK CIRCLE !1 .City /State /Zip: Phone: SAN JOSE CA 95136 ; (408) 910 -0779 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. 5. 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 Installatibn,is required to be included with the documentation the builder provides to the building owner at occupancy. Responsible Builder /Installer.Namec: Responsible Builder /Installer Signature: Tom Tuan Nguyen 7~ xt4xt4w Company Name: (Installing:Subcontractor or General Contractor or Position With Company (Title): Builder /owner) CFO PERFECT HOMES CONSTRUCTION Address: CSLB License: 382 LASSENPARK CIRCLE 556533 City /State /Zip: Phone: Date Signed: SAN JOSE CA 95136 (408) 910 -0779 2015 -06 -30 09:29:33 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: 214- A0101976C- E0200001A -0000 Registration Date /Time: 2015 -06 -30 09:29:33 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2014 -05 -08 Report Generated: 2015 -06 -30 09:21:20 2013 Residential Compliance Schema Version: 0.553SDD CERTIFICATE OF INSTALLATION CF2R- ENV -03 -E Insulation Installation (Page 1 of 8 ) Project Name: GADEPALLI Enforcement Agency: City of Cupertino Permit Number: 14090197 Dwelling Address: 20387 GILLICK WAY City: Cupertino Zip Code: 95014 Medium and light density SPF manufacturers claim various R- values per inch. In California the maximum R -value that con be claimed for ccSPF is on R -value of 5.8 per inch and for ocSPF is an R -value of 3.6 per inch unless documentation is provided showing that the product and /or manufacturer has a current ICC Evaluation Service Report (ESR) that shows compliance with Acceptance Criteria for Spray - Applied Foam Plastic Insulation-- AC377. NOTE: The Energy Efficiency Standards Section 110.7 requires that 'all joints, penetrations and other openings in the building envelope that are potential sources of air leakage shall be caulked, gosketed, weather stripped, or otherwise sealed to limit infiltration and exfiltration.' In areas where spray Foam (SPF) insulation is used, the SPF can be considered the air barrier. Other than rigid board insulation, all other forms of insulation are not considered as an air barrier. A. Roof /Ceiling Insulation f 01 02 -03 i 04 05 06 07 08 09 ID Manufacturer Framing Framing Size J Insulation Type ESR Number Cavity Insulation Insulation Above Deck Below Deck and Brand Material and Spacing R -value Depth (inches) R -value R -value Owens 2x8 @ 16 in This field or This field or This field or 1 Corning Wood O C Fiberglass ._ ,i section is not 19 7.25 section is not section is not applicable applicable applicable 2x4 Top Chord This field or This field or This field or This field or 2 Owens Wood of Roof Truss Fiberglass section is not section is not 3.5 section is not section is not Corning @ 24 in. O.C. applicable applicable applicable applicable Owens 2x4 @ 16 in. This field or This field or This field or 3 Corning Wood O.C. Fiberglass section is not 11 3.S section is not section is not applicable applicable applicable This field or This field or, This field or 4 Owens Wood 2x4 @ 16 in. Fiberglass section is not 11 3.5 section is not section is not Corning O.C. i applicable applicable applicable Registration Number: 214- A0101976C- E0300001A -0000 Registration Date/Time: 2015 -06 -30 09:29:33 HERS Provider: CalCERTS CA Building Energy Efficiency Standards - 2013 Residential Compliance Report Version: 2014 -05 -15 Report Generated: 2015 -06 -30 09:28:02 Schema Version:0.554SDD . . if CERTIFICATE OF INSTALLATION CF2R- ENV -03 -E Insulation Installation (Page 2 of 8 ) B. Wall Insulation 01 02 03 04 05 06 07 08 09 10 Manufacturer Framing Framing Size Cavity Insulation Exterior Wall Interior Wall ID and Brand Material and Spacing Insulation Type ESR Number Insulation Depth (inches) Insulation Insulation and Brand Material and Spacing R -value Depth (inches) R -value R -value This field or R -value R -value R -value 1 Owens Wood 26 @ 16 in. Fiberglass This field or 19 5.5 This field or This field or Owens 2x4 @ 16 in. applicable applicable applicable 1 Corning Wood O.C. Fiberglass section is not 13 3.5 section is not section is not 2 Owens Wood 2x12 @ 16 in. Fiberglass applicable section is not 11.25 applicable applicable Corning O.C. This field or This field or This field or This field or 2 Owens Wood 2x4 @ 16 in. Fiberglass section is not section is not 3.5 section is not section is not Corning O.C. :l. I applicable applicable applicable applicable C. Mass Insulation , This section does not apply to this project. D. Raised Floor Insulation 01 02 03 04 05 06 07 08 09 10 Manufacturer Framing Framing Size Cavity Insulation Exterior Floor Interior ID and Brand Material and Spacing Insulation Type ESR Number Insulation Depth (inches) Insulation Floorinsulation R -value R -value R -value This field or This field or This field or 1 Owens Wood 26 @ 16 in. Fiberglass section is not 19 5.5 section is not section is not Corning O.C. applicable applicable applicable This field or This field or This field or This field or 2 Owens Wood 2x12 @ 16 in. Fiberglass section is not section is not 11.25 section is not section is not Corning O.C. applicable applicable applicable applicable Registration Number: 214- A0101976C- E0300001A -0000 Registration Date/Time: 2015 -06 - 3009:29:33 HERS Provider: CalCERTS CA Building Energy Efficiency Standards - 2013 Residential Compliance Report Version: 2014 -05.15 Report Generated: 2015 -06 -30 09:28:02 . I ) Schema Version:0.SS4SDD CERTIFICATE OF INSTALLATION CFZR- ENV -03 -E Insulation Installation (Page 3 of 8 ) E. Slab Floor /Perimeter Insulation (See F. For Insulation Requirements For Heated Slabs) This section does not apply to this project. F. Heated Slabs Insulation 01 All heated slabs shall be insulated as required by Section 110.8(g). Footings must meet required insulation levels. 02 Insulation shall be installed from the top of the slab, down 16 inches or to the frost line, whichever is greater. Climate zones 1 -15 require R -5, climate zone 16 requires 03 R -10. 04 Alternatively, vertical insulation from top of slab at inside edge of outside wall down to the top of the horizontal insulation. Horizontal insulation from the outside 03 edge of the vertical insulation "extending 4 feet toward the center-of the slab in a direction normal to the outside of the building in plain view. Climate zones 1 -5 06 require R -5, climate zone 16 requires R -10 vertical and R -7 horizontal. The responsible person's signature on this compliance document affirms that all applicable requirements in this table have been met. G. Minimum Mandatory Measures 01 Insulation - 110.8(a): All installed Insulation is certified and listed with Department of Consumer Affairs, Standards for Insulating Material. 02 Insulation - 110.8(b): Urea formaldehyde foam insulation is protected by4 mil polyethylene vapor retarder. 03 Insulation - 110.8(c): Flame spread and smoke density requirements of CBC are met. 04 Raised Floor - 150.0(d): All raised wood -frame floor have a minimum R -19 insulation or equivalent U -factor 05 Slab Floor /Perimeter - 150.0(1): Water absorption rate for the insulation material alone without facings is no greater than 0.3 %; water vapor permeance rate is no greaterthan 2.0 perm /inch and is protected from physical damage and UV light deterioration. 06 Above Grade Exterior Wall - 150.0(c)1: All 2x4 wood -frame walls have a minimum R -13 insulation or equivalent U- factor. 07 Above Grade Exterior wall - 150.0(c)2: All 26 wood -frame walls have a minimum R -19 insulation or equivalent U- factor. 08 Ceiling /Rafter Roof - .150.0(a)1: All wood -frame ceiling have a minimum R -30 insulation or equivalent U- factor. Registration Number: 214- A0101976C- E0300003A -0000 Registration Date/Time: 2015 -06- 3009:29:33 HERS Provider: CaICERTS CA Building Energy Efficiency Standards - 2013 Residential Compliance Report Version! 2014 -OS -1S Report Generated: 2015 -06 -30 09:28:02 J Schema Version: 0554SDD CERTIFICATE OF INSTALLATION CF2R- ENV -03 -E Insulation Installation (Page 4 of 8 ) G. Minimum Mandatory Measures 09 Vapor Retarder - 150(g)1: Class I or II vapor retarder installed on conditioned space side of insulation in exterior walls, vented attics, and unvented attics with 02 air - impermeable insulation in Climate Zones 14 and 16. 10 Vapor Retarder - 150(g)2: Class I or II vapor retarder installed on earth floor of unvented crawlspaces in Climate Zones 1 -16. 11 Vapor Retarder - 150(g)3: Class I or II vapor retarder installed on earth floor of raised floor buildings with controlled ventilation crawlspaces. OS Heated Slabs - 110.8(g): All heated slabs shall be insulated as required. 06 • Insulation shall be installed from the top of the slab, down 16 inches or to the frost line, whichever is greater. Climate zones 1 -5 require R -5, climate zone 16 12 requires R -10. O8 • Alternatively, vertical insulation from top of slab at inside edge of outside wall down to the top of the horizontal insulation. Horizontal insulation from the ,.09 outside edge of the vertical insulation extending 4 feet toward the center of the slab in a direction normal to the outside of the building in plan view. Climate i. zones 1 -5 require R -5, climate zone 16 requires R -10 vertical and R -7 horizontal. The responsible person's signature on this compliance document affirms that all applicable requirements in this table have been met. H. Installed Insulation OS Installed insulation R- values are the same or greater than listed on the CF1R. ' t 02 No gaps or voids between the insulation and framing. 03 No gaps between the sides or ends of batt insulation. 04 Loose -fill insulation must be installed to the minimum installed weight per square foot (density) of the manufacturer's cut sheet for the proposed R- value. OS Batt insulation is not compressed (no stuffing of the insulation into the cavity) and is installed to its full thickness. 06 Insulation is cut around obstructions such as electrical boxes. 07 Batt insulation is delaminated around all plumbing and electrical lines in ceilings, walls and floors. O8 Band joists are insulated to the same R -value as the wall. ,.09 In all narrow cavities the insulation shall be cut to fit or filled with expanding foam. I i Registration Number: 214- A0301976C- E0300003A -0000 Registration Date/Time: 2015 -06 -30 0929:33 HERS Provider: CaICERTS CA Building Energy Efficiency Standards - 2013 Residential Compliance Report Version: 2014.05 -15 Report Generated: 2015 -06.30 09:28:02 ) Schema Version:0.554SDD CERTIFICATE OF INSTALLATION CF2R- ENV -03 -E Insulation Installation (Page 5 of 8 ) H. Installed Insulation 10 Insulation was installed per manufacturer instructions. The responsible person's signature on this compliance document affirms that all applicable requirements in this table have been met. I. Wall Insulation 01 When allowed by manufacturer, low expanding foam shall be used to fill gaps and voids around windows and doors. If not, the cavity must be air tight and filled completely with insulation. Batt insulation must be cut to width. No stuffing allowed. 02 Install wall insulation before installing tubs, showers and fireplaces. 03 Electric panels on walls separating conditioned and unconditioned space are sealed and insulated behind the panel with rigid insulation or expanding foam. 04 All walls of interior closets vented to the outside for HVAC or water, heating equipment have the same R -value and air barrier as the exterior walls and ceiling. Doors are insulated and weather stripped. 05 Ducting not allowed in exterior walls unless insulated to R6 or greater and the insulation and duct are not crushed. Ducting not allowed in 2x4 wall assemblies. I 06, Corner channels, wall intersections, and double sided shear walls insulated to the required R -value before enclosing the wall. 07 Insulation that does not fill the cavity placed against exterior air barrier. - 08 Band joists are insulated to the same R -value as the walls. The responsible person's signature on this compliance document affirms that all applicable requirements In this table have been met. J. Ceiling Roof Insulation 01 Insulation extends to the outside edge of the exterior top plates and is flush against any ventilation dams /baffles. 02 Insulation is in direct contact with ceiling, so there are no gaps between the ceiling and the insulation. 03 For chimneys and flues, the insulation is in contact with the sheet metal collar. Registration Number: 214- A0101976C- E0300001A -0000 Registration DateiTime: 2015 -06 -30 09:29:33 HERS Provider: CaICERTS CA Building Energy Efficiency Standards - 2013 Residential Compliance Report Version: 2014 -05 -15 Report Generated: 2015 -06.30 09:28:02 Schema Version: 0.554SDD CERTIFICATE OF INSTALLATION CFZR- ENV -03 -E Insulation Installation (Page 6 of 8 J. Ceiling Roof Insulation 04 Can lights are covered with insulation to the same depth as required by the CF1R for ceiling insulation. If not an area weighted calculation is required to be turned in 02 with this form. 05 Walkways and mechanical platforms insulated to the same R -value as required for the ceiling. If not an area weighted calculation is required to be turned in with this 04 form. 06 Insulate soffits by adding an air barrier and cover with insulation, or insulate the entire soffit including floor and walls. 07 Knee walls and skylight shafts are insulated to the wall R -value and in full contact with the interior air barrier. If framing on these surfaces is laid flat batt insulation is cut to fit around the framing. Batt insulation is not allowed to be draped over the framing. 08 Attic access doors insulated to the same R -value as ceiling. The insulation is permanently attached using adhesive or mechanical fasteners. 09 Attic access must be surrounded with a dam at least the same depth as the insulation to prevent loss of ceiling insulation. 10 Batt insulation cut to fit around cross bracings and truss webs In attic. The responsible person's signature on this compliance document affirms that all applicable requirements In this table have been met. K. Raised Floor Insulation i 01 Insulation in full contact with subfloor. 02 Insulation hangers spaced at 18 inches or less, insulation hangers must not compress insulation. 03 If netting or mesh is used, the cavity under the floor is filled and in contact with the subfloor. 04 If the basement is conditioned the walls adjacent to the crawlspace must meet minimum wall R -value requirements. This includes framed stem walls, and vertical concrete retaining walls. 05 If access to the crawl space is from the conditioned area, the raised floor must have an airtight insulated access hatch. The responsible person's signature on this compliance document affirms that all applicable requirements in this table have been met. Registration Number: 214- A0101976C- E0300001A -0000 Registration Datefrime: 2015 -06- 3009:29:33 HERS Provider: CaICERTS CA Building Energy Efficiency Standards - 2013 Residential Compliance Report Version: 2014 -05 -15 Report Generated: 2015 -06 -30 09:28:02 1 Schema Version: O.SS4SDD CERTIFICATE OF INSTALLATION CF2R- ENV -03 -E Insulation Installation (Page 7 of 8 ) L. Floor Above Garage Insulation 01 Insulation must be in full contact with subfloor if the air barrier is at the band joist at the garage /house wall. 02 Insulation hangers spaced at 18 inches or less, insulation hangers must not compress insulation. 03 If netting or mesh is used, the cavity under the floor is filled and in contact with the subfloor. 04 If air barrier is at the perimeter of the garage, below conditioned subfloor, the insulation is placed on the garage ceiling. The perimeter of subfloor is also insulated. The responsible person's signature on this compliance document affirms that all applicable requirements in this table have been met. M. Cantilevered Floor Insulation { i 01 Insulation in full contact,with cantilevered subfloor. Insulation hangers spaced at 18 inches or less, insulation hangers do not compress insulation. 02 If netting or mesh is used, the cavity under the floor is filled and in contact with the subfloor. i 03 Sealed blocking is installed between joists where wall rim joist would be located in the absence of a cantilever. Insulation is placed on both sides of this block. The responsible person's signature on this compliance document affirms that all applicable requirements in this table have been met. N. Attached Porch Roof Insulation 01 1 The exterior insulated wall at the intersection with the porch roof is fully insulated above, below and behind the roof line. i 1 02 1 Where truss framing is used, airtight blocking is at the top and bottom of each wall /roof section and insulated. The responsible person's signature on this compliance document affirms that all applicable requirements in this table have been met. Registration Number: 214- A0101976C- E0300001A -0000 (Registration Date/Time: 2015 -06- 3009:29:33 HERS Provider: Ca10ERTS CA Building Energy Efficiency Standards - 2013 Residential Compliance Report Version: 2014 -05 -15 Report Generated: 2015 -06 -30 09:28:02 Schema Version: 0.554SDD CERTIFICATE OF INSTALLATION CF2R- ENV -03 -E Insulation Installation (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: �� Tom Tuan Nguyen Company: Signature Date: PERFECT HOMES CONSTRUCTION 2015 -06 -30 09:29:33 Address: CEA/ HERS Certification Identification (if applicable): 382 LASSENPARK CIRCLE City /State/Zip: Phone: SAN JOSE CA 95136 (408) 910 -0779 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. 1 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 permits) 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: Tom Tuan Nguyen �� Pal✓ Company Name: (Installing Subcontractor or General Contractoror Builder /Owner) Position With Company (Title): PERFECT HOMES CONSTRUCTION CFO Address: CSLB License: 382 LASSENPARK CIRCLE 556533 City /State/Zip: Phone: Date Signed: SAN JOSE CA 95136 (408) 910 -0779 2015 -06 -30 09:29:33 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: 214- A0301976C- E0300001A -0000 Registration Date/Time: 2015 -06- 3009:29:33 HERS Provider: CaICERTS CA Building Energy Efficiency Standards - 2013 Residential Compliance Report Version: 2014 -05 -15 Report Generated: 2015 -06 -30 09:28:02 Schema Version:0.554SDD CERTIFICATE OF INSTALLATION CF2R- MCH -20 -H Duct Leakage Diagnostic Test (Page 1 of 3 ) Project Name: GADEPALLI Enforcement Agency: Cupertino City of Permit Number: 14090197 Dwelling Address: 20387 GILLICK WAY 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 Duct System Compliance Category New RICH -20a - Completely New Duct System B. Duct Leakage Diagnostic Test 01 Condenser Nominal Cooling Capacity (ton) 5 02 Heating Capacity (kBtu /h) 85 03 Conditioned Floor Area served by this HVAC system (ft2) 2221 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 Cooling system method 08 Measured AHUAirflow This field or section is not applicable 09 Calculated Target Allowable Duct Leakage (cfm) 120 10 Actual duct leakage rate from leakage test measurement (cfm) 104 11 Compliance Statement: System passes leakage test Registration Number: 214- A0101976C- M2000001A -0000 Registration Date /Time: 2015 -06 -30 08:47:11 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2014 -05 -08 Report Generated: 2015 -06 -22 08:21:12 2013 Residential Compliance Schema Version: 0.515DD CERTIFICATE OF INSTALLATION CFZR- 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) ducts for Central Fan Integrated (CFI) ventilation systems, shall not be sealed /taped off during duct leakage 02 testing. CFI OA ducts that utilize controlled motorized dampers, that open only when OA ventilation is required to meet ASHRAE Standard 62.2, and close when OA ventilation is not required, may be configured to the closed position during duct leakage testing. 1.03 All supply and return register boots were sealed to the drywall. 04" Building cavities were not used as plenums or platform returns in lieu of ducts. '05 If cloth backed tape was used it was covered with Mastic and draw bands. 06 All connection points,between the:air handler and the supply and return plenums are completely sealed. Visual Inspection at Final Construction Stage (applicable if system was tested at rough -in) After installing the interior finishing wall and verifying that the above rough -in tests was completed, the following procedure must be performed 07 For all supply and return registers, verify that the spaces between the register boot and the interior finishing wall are properly sealed. 08 If the house rough - induct 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.jdints 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: 214- A0101976C- M2000001A -0000 Registration Date /Time: 2015 -06 -30 08:47:11 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2014-05 -08 Report Generated: 2015 -06 -22 08:21:12 2013 Residential Compliance Schema Version: 0.51SDD 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: John Kemp company: Signature Date: 2015 -06 -30 08:45:57 Simple Home Energy Address: CEA/ HERS Certification Identification (if applicable): P.O. Box /456 ; CC2006167 City /State /Zip: Phone: 1877 Los Gatos CA 95031 300 4665 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 o0ristallation 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: Tom Tuan Nguyen Company Name: (Installing Subcontractor or General Contractor or Position With Company (Title): Builder /Owner) Owner PERFECT HOMES CONSTRUCTION Address: CSLB License: 382 LASSENPARK CIRCLE 556533 City /State /Zip: Phone: Date Signed: SAN JOSE CA 95136 (408) 910 -0779 2015 -06 -30 08:47:11 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 no way implies Registration Provider responsibility for the accuracy of the information. Registration Number 214- A0101976C- M2000001A -0000 Registration Date /Time: 2015 -06 -30 08:47:11 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2014 -05 -08 Report Generated: 2015 -06 -22 08:21:12 2013 Residential Compliance Schema Version: 0.51SDD CERTIFICATE OF INSTALLATION CF2R- MCH -22 -H Space Conditioning System Fan Efficacy (Page 1 of 3 ) Project Name: GADEPALLI Enforcement Agency: Cupertino City of Permit Number: 14090197 Dwelling Address: 20387 GILLICK WAY City: Cupertino Zip Code: 95014 A. Ducted Cooling System Information 01- i System Identification or Name System 1 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 2015 -06 -11 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 910 02 Actual Tested Airflow from MCH -23 (cfm) 1750 03 Required Fan Efficacy (watts /cfm) 0.58 04 Actual an Efficacy (watts /cfm) 0.52 05 Compliance Statement: System fan efficacy complies Registration Number: 214- A0101976C- M2200001A -0000 Registration Date/Time: 2015 -06 -30 08:47:11 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2014 -05 -08 Report Generated: 2015 -06 -23 21:05:32 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.rat'e. and!fari- watt•draw shall-be simultaneous measurements when used to calculate the Fan Efficacy tested value. '05 Multi -speed compressor space coolirig'systerris 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: 214- A0101976C- M2200001A -0000 Registration Date /Time: 2015 -06 -30 08:47:11 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2014 -05 -03 Report Generated: 2015 -06 -23 21:05:32 2013 Residential Compliance Schema Version: 0.525DD 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: John Kemp company: Signature Date: 2015 -06 -30 08:45:57 Simple Home Energy Address: CEA/ HERS Certification Identification (if applicable): P.O. Box /456 ICC2006167 City /State /Zip: ; Phone: Los Gatos CA 95031 877 300 4665 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. 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. 1 6.. 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: Tom Tuan Nguyen Company Name: (Installing Subcontractor or General Contractor or Position With Company (Title): Builder /Owner) PERFECT HOMES CONSTRUCTION Address: CSLB License: 382 LASSENPARK CIRCLE 556533 City /State /Zip: Phone: Date Signed: SAN JOSE CA 95136 (408) 910 -0779 2015 -06 -30 08:47:11 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: 214- A0101976C- M2200001A -0000 Registration Date /Time: 2015 -06 -30 08:47:11 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2014 -05 -08 Report Generated: 2015 -06 -23 21:05:32 2013 Residential Compliance Schema Version: 0.52SDD CERTIFICATE OF INSTALLATION CF2R- MCH -23 -H Space Conditioning System Airflow Rate (Page 1 of 3 ) Project Name: GADEPALLI Enforcement Agency: Cupertino City of Permit Number: 14090197 Dwelling Address: 20387 GILLICK WAY 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 2015 -06 -11 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. Ol 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 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: 214- A0101976C- M2300001A -0000 Registration Date/Time: 2015 -06 -30 08:47:11 HERS Provider: CalCERTS CA Building Energy Efficiency Standards Report Version: 2014 -05 -08 Report Generated: 2015 -06 -23 21:03:01 2013 Residential Compliance Schema Version: 0.555SDD 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 ; i Required Minimum System Airflow Rate (cfm /ton) 350 - 02 ' Required Minimum System Airflow Target (cfm) 1750 03 Actual System Airflow Rate Measurement (cfm) 1750 04 i 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: 214- A0101976C- M2300001A -0000 Registration Date /Time: 2015 -06 -30 08:47:11 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2014 -05 -08 Report Generated: 2015 -06 -23 21:03:01 2013 Residential Compliance Schema Version: 0.555SDD 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: John Kemp Company: Signature Date: 2015 -06 -30 08:45:57 Simple Home Energy Address: CEA/ HERS Certification Identification (if applicable): PA:,BW456 CC2006167 City /State /Zip: Phone: Los Gatos CA 95031 877 300 4665 Responsible Person's Declaration statement I certify the following under penalty of perjury, under the laws of the State of California: J. 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: Tom Tuan Nguyen Company Name: (Installing Subcontractor or General Contractor or Position With Company (Title): Builder /Owner) Owner PERFECT HOMES CONSTRUCTION Address: CSLB License: 382 LASSENPARK CIRCLE 556533 City /State /Zip: Phone: Date Signed: SAN JOSE CA 95136 (408) 910 -0779 2015 -06 -30 08:47:11 Third Party Quality Control Program ( TPQCP) Status: Name of TPQCP (if applicable): Digitally signed byCaICERTS. 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: 214- AO101976C- M2300001A -0000 Registration Date /Time: 2015 -06 -30 08:47:11 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2014 -05 -08 Report Generated: 2015 -06 -23 21:03:01 2013 Residential Compliance Schema Version: 0.555SDD CERTIFICATE OF VERIFICATION CF3R- MCH -20 -H Duct Leakage Diagnostic Test (Page 1 of 3 ) Project Name: GADEPALLI Enforcement Agency: Cupertino City of Permit Number: 14090197 Dwelling Address: 20387 GILLICK WAY 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 Duct System Compliance Category New iVICH -20a - Completely New Duct System B. Duct Leakage Diagnostic Test 01 Condenser Nominal Cooling Capacity (ton) 5 . 02 Heating Capacity (kBtu /h) 85 03 Conditioned Floor Area served by this HVAC system (ft2) 2221 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 Cooling system method 08 Measured AHUAirflow This field or section is not applicable 09 Calculated Target Allowable Duct Leakage (cfm) 120 10 Actual duct leakage rate from leakage test measurement (cfm) 104 11 Compliance Statement: System passes leakage test 12 Notes: Registration Number: 214- A0101976C- M2000001A -M20A Registration Date /Time: 2015 -06 -30 08:53:00 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2014 -05 -08 Report Generated: 2015 -06 -30 08:49:46 2013 Residential Compliance Schema Version: 0.551SDD CERTIFICATE OF VERIFICATION CF3R- 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) ducts for Central Fan Integrated (CFI) ventilation systems, shall not be sealed /taped off during duct leakage 02 testing. CFI OA ducts that utilize controlled motorized dampers, that open only when OA ventilation is required to meet ASHRAE Standard 62.2, and close when OA ventilation is not required, may be configured 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 theiair handler and the supply and return plenums are completely sealed. Visual Inspection at Final Construction Stage (applicable if system was tested at rough -in) After installing the interior finishing wall and verifying that the above rough -in tests was completed, the following procedure must be performed 07 For all supply and return registers, verify that the spaces between the register boot and the interior finishing wall are properly sealed. 08 If the house rough -in duct leakage test was conducted without an air handler installed, inspect the connection points between the air handler and the supply and ,return plenums to verify that the connection points are properly sealed. 09 Inspect all joints to ensure that no cloth backed rubber adhesive duct tape is used. 10 Verification Status: Pass 11 Correction Notes for this table: The responsible persons signature on this compliance document affirms that all applicable requirements in this table have been met unless otherwise noted in the Verification Status and the Corrections Notes in this table. D. Determination of HERS Verification Compliance All applicable sections of this document shall indicate compliance with the specified verification protocol requirements in order for this Certificate of Verification as a whole to be determined to be in compliance. 01 1 Complies: All specified verification protocol requirements on this document are met. ' Registration Number: 214- A0101976C- M2000001A -M20A Registration Date /Time: 2015 -06 -30 08:53:00 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2014 -05 -08 Report Generated: 2015 -06 -30 08:49:46 2013 Residential Compliance Schema Version: 0.551SDD CERTIFICATE OF VERIFICATION CF3R- MCH -20 -H Duct Leakage Diagnostic Test (Page 3 of 3 ) Documentation Author's Declaration Statement 1. f certify that this Certificate of Verification documentation is accurate and complete. Documentation Author Name: Documentation Author Signature: John Kemp Company: Date Signed: Simple Home Energy 2015 -06 -30 08:53:00 Address: _ CEA/ HERS Certification Identification (if applicable): P.O. Box 456 City /State /Zip: Phone: Los Gatos CA 95031 877 300 4665 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 Certificates) 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): PERFECT HOMES CONSTRUCTION Responsible Builder or Installer Name: CSLB License: Tom Tuan Nguyen 556533 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: Simple Home Energy Responsible Rater Name: Responsible Rater Signature: John Kemp Responsible Rater Certification Number w/ this HERS Provider: Date Signed: CC2006167 2015 -06 -30 08:53:00 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: 214- A0101976C- M2000001A -M20A Registration Date /Time: 2015 -06 -30 08:53:00 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2014 -05 -08 Report Generated: 2015 -06 -30 08:49:46 2013 Residential Compliance Schema Version: 0.551SDD CERTIFICATE OF VERIFICATION CHR- MCH -22 -14 Space Conditioning System Fan Efficacy (Page 1 of 3 ) Project Name: GADEPALLI Enforcement Agency: Cupertino City of Permit Number: 14090197 Dwelling Address: 20387 GILLICK WAY 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 i 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 2015 -06 -11 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. 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 910 02 Actual Tested Airflow from MCH -23 (cfm) 1750 03 Required Fan Efficacy (watts /cfm) 0.58 04 Actual an Efficacy (watts /cfm) 0.52 05 Compliance Statement: System fan efficacy complies Registration Number: 214- A0101976C- M2200001A -M22A Registration Date /Time: 2015 -06 -30 08:53:00 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2014 -05 -08 Report Generated: 2015 -06 -30 08:52:33 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 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. 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 Compliance StatementComplies: All specified verification protocol requirements on this document are met. Registration Number: 214- A0101976C- M2200001A -M22A Registration Date /Time: 2015 -06 -30 08:53:00 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2014 -05 -08 Report Generated: 2015 -06 -30 08:52:33 2013 Residential Compliance Schema Version: 0.515DD 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: John Kemp Company: Date Signed: Simple Home,Energy 2015 -06 -30 08:53:00 Address: _ .... CEA/ HERS Certification Identification (if applicable): P.O. Box 456 City /State /Zip: Phone: Los Gatos CA 95031 877 300 4665 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 copyM 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. I Builder Or Installer Information As Shown On The Certificate Of Installation Company Name (Installing Subcontractor, General Contractor, or Builder /Owner): PERFECT HOMES CONSTRUCTION Responsible Builder or Installer Name: CSLS License: Tom Tuan Nguyen 556533 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: Simple Home Energy Responsible Rater Name: Responsible Rater Signature:p s— John Kemp Responsible Rater Certification Number w/ this HERS Provider: Date Signed: CC2006167 2015 -06 -30 08:53:00 Digitally signed by CalCERTS. 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: 214- A0101976C- M2200001A -M22A Registration Date /Time: 2015 -06 -30 08:53:00 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2014 -05 -08 Report Generated: 2015 -06 -30 08:52:33 2013 Residential Compliance Schema Version: 0.515DD CERTIFICATE OF VERIFICATION CF3R- MCH -23 -H Space Conditioning System Airflow Rate (Page 1 of 4 ) Project Name: GADEPALLI Enforcement Agency: Cupertino City of Permit Number: 14090197 Dwelling Address: 20387 GILLICK WAY 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 2015 -06 -11 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 the I 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. Airflow Rate Measurement Type used for this airflow rate Traditional Flow Capture Hood according to procedure in O1 verification. RA3.3.3.1.4 02 Manufacturer of Airflow Measurement Apparatus Kanomax 03 Model number of Airflow Measurement Apparatus 6710 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: 214- A0101976C- M2300001A -M23A Registration Date /Time: 2015 -06 -30 08:53:00 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2014 -05 -08 Report Generated: 2015 -06 -30 08:52:02 2013 Residential Compliance Schema Version: 0.555SDD CERTIFICATE OF VERIFICATION CF3R- MCH -23 -H 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) 1750 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: 214- A0101976C- M2300001A -M23A Registration Date/Time: 2015 -06 -30 08:53:00 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2014 -05 -08 Report Generated: 2015 -06 -30 08:52:02 2013 Residential Compliance Schema Version: 0.555SDD 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 1 Complies: All specified verification protocol requirements on this document are met. Registration Number: 214- A0101976C- M2300001A -M23A Registration Date /Time: 2015 -06 -30 08:53:00 HERS Provider: CalCERTS CA Building Energy Efficiency Standards Report Version: 2014 -05 -08 Report Generated: 2015 -06 -30 08:52:02 2013 Residential Compliance Schema Version: 0.5555DD 1 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: John Kemp 8 Company: Date Signed: Simple Home Energy 2015 -06 -30 08:53:00 Address: CEA/ HERS Certification Identification (if applicable): P.O. Box.456 CC2006167 City /State /Zip: Phone: Los Gatos CA 95031 877 300 4665 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 Verificatibn,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): PERFECT HOMES CONSTRUCTION Responsible Builder or Installer Name: CSLB License: Tom Tuan Nguyen 556533 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: Simple Home Energy Responsible Rater Name: Responsible Rater Signature: John Kemp Responsible Rater Certification Number w/ this HERS Provider: Date Signed: CC2006167 2015 -06 -30 08:53:00 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: 214- A0101976C- M2300001A -M23A Registration Date /Time: 2015 -06 -30 08:53:00 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2014 -05 -08 Report Generated: 2015 -06 -30 08:52:02 2013 Residential Compliance Schema Version: 0.555SDD