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12070089CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 18751 PENDERGAST AVE CONTRACTOR: JIGSAW DESIGN BUILD PERMIT NO: 12070089 OWNER'S NAME: HAR-EL OPHER Y AND NAOMI 101 IST STREET 9539 DATE ISSUED: 12/2112012 OWNER'S PHONE: 4088357564 LOS ALTOS, CA 94022 PHONE NO: 650-305-1103 ❑ LI a NSED CONTRACTOR'S DECLARATION 9D� 0rg BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic. # r F Contractorq"ew t-Srl"rPl!&14ate AFT�- 2/ X4%2 MECH RESIDENTIAL COMMERCIAL I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: CONSTRUCT I STORY 2,844 SQ FT, ATTACHED GARAGE (commencing with Section 7000) of Division 3 of the Business & Professions 463 SQ FT AND DECK 30 SQ FT-SANITARY IS IN SUNNYVALE'S Code and that my license is in full force and effect. JURISDICTION I hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain a certificate of consent to self-insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this Sq. Ft Floor Area: Valuation: $500000 permit is issued. APPLICANT CERTIFICATION APN Number: 37527033.00 Occupancy Type: 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, PERMIT EXPIRES IF WORK IS NOT STARTED costs, and expenses which may accrue against said City in consequence of the granting of this permit dditionally, the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR with all non-point so regulations per the Cupertino Municipal Code, Section 180 DAYS FROM LAST CALLED INSPECTION. 9.18. Signature Date �� f Issued by: �� �! �L Date: ElOWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of RE-ROOFS: the following two reasons: All roofs shall be inspected prior to any roofing material being installed. If a roof is I, as owner of the property, or my employees with wages as their sole compensation, installed without first obtaining an inspection, I agree to remove all new materials for will do the work, and the structure is not intended or offered for sale (Sec.7044, inspection. Business & Professions Code) I, as owner of the property, am exclusively contracting with licensed contractors to Signature of Applicant: Date: construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER declarations: 1 have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain Worker's Compensation Insurance, as provided for by California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain Section 3700 of the Labor Code, for the performance of the work for which this compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should 1 store or handle hazardous material. permit is issued. Additionally, should 1 use equipment or devices which emit hazardous air certify that in the performance of the work for which this permit is issued, I shall contaminants as defined by the Bay Area Air Quality Management District I will not employ any person in any manner so as to become subject to the Worker's maintaJcom,0*rCnce with the Cupertino Municipal Code, Chapter 9.12 and the Compensation laws of California. If, after making this certificate of exemption, I Health ode, Sections 25505, 25533, and 25534. become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. Owner ized agent: C / ZG/ 2— Date: APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is CONSTRUCTION LENDING AGENCY correct. I agree to comply with all city and county ordinances and state laws relating Ieby affirm that there is a construction lending agency for the performance of work's to building construction, and hereby authorize representatives of this city to enter for which this permit is issued (Sec. 3097, Civ C.) upon the above mentioned property for inspection purposes. (We) agree to save Lender's Name indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the Lender's Address granting of this permit. Additionally, the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code, Section ARCHITECT'S DECLARATION 9.18. I understand my plans shall be used as public records. Signature Date Licensed Professional CONSTRUCTION PERM7 APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION �vb 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 CU 79TINO (408) 777-3228 ^ FAX (408) 777-3333 • building cDcugertino.org FXMW CONSTRUCTION ❑ ADDITION ❑ ALTERATION / TI ❑ REVISION/ DEFERRED ORIGINAL PERMIT # PROTECT ADDRESS , ^ppp��( J/IC APN 1 5 �� v 3 OWNER NAME V V 1 1 Y \v1 PHONE _fit 2j� �5� (J✓ I E-MAIL STREETADDRESS n CITY. STATE. IIP FAX �p CONTACT NAME p \^`^1 A4A Y1 1 1 PHONE C _ Z2/,�` E MAII` 1\<�,SS9:3g 97U=ADDRESS (/ 1 �, CITY, STATE, ZIP / g earn �e ❑ OWNER ❑ OWNER.BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGYEER ❑ DEVEIOPER ❑ TENANT CONTRACTOR NAME ti LICENSE NUMBER LICENSE TYPE �a1 BUS. LIC N COMPANY NAME \ § E MALI U v,�� i �u i 1^n �� FAX 1 ` STItEEIADDRESS �` ��• ZIP © _ V-zr� , PHONE/_ „j O ARCHITE GMj! AME LICENSE NUMB'E'R BUS. LIC COMPANY NAME' E -MA FAX c� -p j ` STREET ADDRESS 1 'l \ 1 CITY, STATE IIP P`t - 655 -13J h r 1` l� JCi®� d1 1 DESCRIPTION OF WORK ^ oP6A0A- wVI awl EXISTING USEPROPOSED USE +lJ e-,-) 1 „4 �1 CONSTR. TYPE I STORIES USE TYPE occ. SQJ-7. VALUATION (S) TG N ooR AREA O n7�EA�, a i VJ BATHROOM REMODEL AREA �/ KITCHEN I OTHER REMODEL AREA REMODEL AREA PORCHAREA DECK AREA TOTALDECKlPORCHAREA GARAGEAREA: DETACH TTACH M DWELLING - uNm: IS A SECOND IIINIT ❑YES BEnVG ADDED? NO SECOND STORY �'ES ADDITION? 0 PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF IS TBE BLDG AN ❑ YES RECEIVED By: ToTAL VALUATION: PLANNING APPL # []NO PLANNING APPROVAL LETTER EICHLER ROME?19NO By my signature below, I certify to each of rhe following I am the property owner or authorized agenf to act on the property owner's behalf. I have read this application and the information I have provid d is correct. I have read the Description ofWork and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to buil ' construc ' I authorize representatives of Cupertino to enter the above -identified property for inspection purposes. I Date: ' VZ54 Signature of Applicant/Agent SUPPLEIYMNTAL INFORMATION REQUIRED PLAN CHECK TYPE ROUTING SLIP ❑ ovER-TB>r-cotmTEx 21IIII DING PLAN xEvzEw 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. FLAANNMG PLAN REVIEW _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ��❑, �EYPRE��SS �AMARD � IOPUBcl 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 AVIARY SEWER DISTRICT submittal ofBuilding Permit application. ❑ ENVERONMENTALHEALTH 31dgApp_2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION ADDRESS: 18751 pendergast ave. DATE: 07/12/2012 REVIEWED BY: bobs. APN: BP#: `VALUATION: 1$500,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: New Construction PRIMARY SFD or Duplex 2nd Unit? ' Yes • No PENTAMATION 1R3SFDW USE: PERMIT TYPE: WORK sfd new living space 2844 s.f., garo a 463 s.f. deck 30 s.f.. SCOPE OCCUPANCY TYPE: TYPE OF CONSTR. FLR AREA s.f. PC FEES PC FEE ID BP FEES BP FEE ID R-3 (Custom) II-B,111-B,IV,V-B 3,357 $2,928.44 IR3PLNCK $2,978.61 IR3INSP $2,978.61 Suppl. Insp. Fee:Q Reg. ® OT 0,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Tax: IBCONSTAXR 1 new units $595.41 ,ldininictrative Fee: 0 Work Without Permit? ® Yes E) No $0.00 Advanced Planning Fee: IPLLONGR TOTALS: 3,357 $2,928.44 $2,978.61 $50.00 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 nreliminary information availahle and are only an estimate_ Contact the Dent for addn'l info_ }FEE ITEMS (Fee Resolution 11-053 Eff: 7/1/11) Wech. flan Check Phnnh. Plcnt Check Elec. Plan Check .blc'ch. Permit Fee: [Ph -h. Permit Tee: Elec. Permit Fee: Ocher Alech. /nsp Other Plumb Insp.Li Other Flee. Insp, I11cch. Insp. Fee: Phimb. Insp. Fee: Eley. Insp. Fee: 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 nreliminary information availahle and are only an estimate_ Contact the Dent for addn'l info_ }FEE ITEMS (Fee Resolution 11-053 Eff: 7/1/11) FEE QTY/FEE MISC ITEMS Plan Check Fee: $2,928.44 Select a Misc Bldg/Structure or Element of a Building Suppl. PC Fee: 0 Reg. ® OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $2,978.61 Suppl. Insp. Fee:Q Reg. ® OT 0,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Tax: IBCONSTAXR 1 new units $595.41 ,ldininictrative Fee: 0 Work Without Permit? ® Yes E) No $0.00 Advanced Planning Fee: IPLLONGR $436.41 Select a Non -Residential Q Building or Structure A Tru����l Documentation Fees: Strong Motion Fee: IBSEISMICR $50.00 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $20.00 SUBTOTALS: 1 $7,008.87 $0.00 TOTAL FEE: 1 $7,008.87 Revised: 07/01/2012 <<� CUPERTONO 19�v CONTRACTOR / SUBCONTRACTOR LIST Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 Fax: 408-777-3333 JOB ADDRESS: j PERMIT # 0 O O WNER' S NAME: /2 / cti (%�' / -E c— PHONE # 6 -Fd 267 %/f1 GENERAL CONTRACTOR: ;�Ie j'' �'�"/C� BUSINESS LICENSE # ADDRESS: /YU/ 1-Y- ler C1 CITY/ZIPCODE: 2 Z *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR ]FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not casing any subcontractors: Signature Please check applicable subcontractors and complete the following information: Date V SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork © e/1L &T Z pY Cement Finishing Electrical Excavation Fencing 3 14-- bi/Y L.1�.5'C�c Flooring/ Carpeting Linoleum/ Wood j P,0AALTj L PHIS Y0"t-2ff I//— Glass / Glazing Heating Insulation 110Q1LA7701V Landscaping0[%. L-�1 rv�-� 47-�2k— Lathing Masonry Painting / Wallpaper Paving Plumbing Roofing J�fV l —1-i 1 f�� i'l �� o? Septic Tank Sheet Metal Sheet Rock z� J, WTI24 Tile Owner / Contractor Signature Date r o jz I Oci-1 a. 01c] Oualdinnb ins7dcvism; Dcpa` 'YC mt citl-Iri"U=2vorn) 1 O Ftp ; Tp.r-rri' Av4� . Cup]lzvii u. V alifurnna()50p4 RE- ZhLl RESMLCL-1876 ➢ Fac-ndl :c mst Avc, /up?crs➢no. CA I �03Dr�D -Phos os to "ardiiLfv CGi� In Scution 1701- 1707 of the 2W3 Califfoa- is Building Cade, we, ita�-'e pzo i&d : �ruc=a➢ fcz Chc following, co sttructialu: Thi �: s:gruc mal arhscn:mtnnr= cr-,«,rzcfims v;crc- p erfca-medl by a Regislered Civil Agineer in the Raw of �.liiror i Base upea inspAz' ops [wmuTcullledf and ai lr subsl=tlatiny ffoparts, if is our pkrofessuo na l judgr,TDr.m trit, to the test ofr nT Lam ledge, the obsened sti-ue aaaf. A ork %.&s performed in a=ordance ik O .lw appaive d puns,. spz6LcrJ--ins- Ltd apphcable wovta7nanship Apra: vosoons of the: f_'a9ifomia Bufldirfl Code - Vel mtly 'vous. pFf i; I G ifr'@ I INSTALLATION-CER-T-IFICATE CF -6R -ENV -01 Envelo - Insulation; Roofi3t ; Fenesii 'on ft e f 3) _. Site Tress: Enforcement A eney: Permit umber: If more tha erson has responsibility for installation of the items on this c rtificate, each person .shall prepare applicable to the portio re responsible; alt Lively, the person with chief responsibility for construction shall prepare and sign this certificate for the entire construction. e Mandatory Measures with check boxes require to be checked to ensure the mandatory measures have been met. Description of Insulation I. RAISED FLOOR Material:Brand Thickness (inches): Thermal Resistance (R -Value): ❑ § 150(d): Minimum R-13 insulation in raised wood -frame floor or equivalent U -factor. 2. SLAB FLOOR/PERIMETER Material: - Brand Name: Thickness (inches): Thermal Resistance (R -Value): Perimeter Insulation Depth (inches): ❑ § 150(1): Water absorption rate for the insulation material alone without facings is no greater than 03%; water vapor permeance rate is no greater than 2.0 perm/inch and shall be protected from physical damage and UV light deterioration. 3. EXTERIOR WALL a. Insulation Type (e.x. Batt, Loose Fill, Spray Foam) b.. Inst ulatioiType (e.x. Batt, Loose Fill, Spray Foam) Brand: a. Thermal Resistance (R -Value): b. Thermal Resistance (R -Value): _l 3 Spray/Loose fill) Installed Actual Thickness Spray/Loose fill) (inches): (2_ "757 Contractor's min installed weight/ft' Ib Manufacturer's installed weight per square foot to achieve Thermal Resistance (R -Value) ❑ § 150(c): Minimum R-13 insulation in wood -frame wall or equivalent U -factor. Exterior Foam Sheathing (rigid Insulation) Material: Thickness (inches) : 4. FOUNDATION WALL Material: Thickness (inches): Brand Name: Thermal Resistance (R -Value) : Brand Name: Thermal Resistance (R -Value): S. CEILING M Batt or Blanket Type: V�Fi-T Brand Name: Loose Fill Type: J e Thermal Resistance (R -Value): 3.1?p Spray Foam Type: Brand Name: Installed Actual Thickness (inches): Contractor's min installed weight/ft' lb Manufacturer's installed weight per square foot to achieve Thermal Resistance (R -Value): ❑ §150(a): Minimum R-19 insulation in wood -frame ceiling or equivalent U -factor. 6. ATTIC ROOF INSULATION AND/OR ATTIC RADIANT BARRIER Material: Brand Name: Material: Brand Name: Thickness (inches): Thermal Resistance (R -Value): ❑ §118(a): Insulation installed meets Standards .for Insulating Material. 13 § 150(g): Mandatory Vapor barrier installed in Climate Zones 14 or 16. I INSTALLATION CERTIFICATE CF -6R -ENV -01 I Envelope — Insulation; Roofing; Fenestration (Page 2 of 3) Site Address: Enforcement Agency: Permit Number: 7S- 1- Description of ng Products CRRC Product ID Manufacturer Manufacturer/Brand Name LIKE RODUC S Product Roof .Roof Product Initial Solar Aged Solar Thermal Number Information Brand/Model Type Area Sloe Weigh to Reflectance Retlectance4 F.,mittance 2 ❑3 3 ❑9 4 ❑3 5 1. The CRRC Product ID Number can be obtained from the Coot Roof Rating Council's Rated Product Directory at ww. coolroofs. org/products/search.php 2. The weight in lbs per square feet of the roofing product being installed. 3. Check box if the Aged Reflectance is a calculated value using the equation below, footnote 4. 4. If the aged reflectance is not available in the Cool Roof Rating Council's Rated Product Directory then use the initial reflectance value from the directory and use the equation 0.2+0.7( ,,j,,qt — 0.2) to obtain a calculated aged value. ✓OCHECKAPPLICABLE BOXBELOWIFEXEMPTFROMIRE ROOFING PRODUCT "COOL ROOF "'RE'_OUIREVEYT: ❑ The roof area covered by building integrated photovoltaic panels and building integrated solar thermal panels are exempt from the above Cool Roof criteria ❑ Roof constructions that have thermal mass over the roof membrane with a weight of at least 25 lb/fis exempted from the above Cool Roof criteria. 7o apply Liquid Field Applied Coatings, the coating must be applied with a minimum dry mil thickness of 20 mils across the entire roof surface and meet minimum performance requirements listed in 5118(1 3 and Table 118-C. Select the applicable coating ❑ Aluminum -Pigmented Asphalt Roof Coating ❑ Cement -Based Roof Coating ❑ Other ✓ ❑ CRRC-i Label Attached to CF -6R (?dote if no CRRC-1 label is available, this compliance method cannot be used and another method is required to meet compliance). FENESTRATION/GLAZING EIle.(GROUP Manufacturer/Brand Name LIKE RODUC S Product U- factor' Product SHGC' # of Panes NFRC Certified'' 2 Total Quantity of Like Product (Optional) Area ftz Add. Exterior Shading Dev. or Overhang Comments/ Location/ Special Features I _ ! L� .2—to Z— N FAZ, 3� 2 3 4 5 6 7. 8- 1, Use values from a fene stration product's NFRC Certified Label. For fenestration products without an NFRC label, use the default values from Section 116, Table 116-A and 116-B of the 2008 Energy Efficiency Standards. 2..NFRC Label Certificates shall not be removed until the building inspector has verified the eficiency. Enter Yes or No. ,X § 116(a)1: Doors and windows between conditioned and unconditioned spaces designed to limit air leakage. eS 116(a)2 and 3: Actual fenestration products installed are equivalent to or have a lower U -factor and/or a lower SHGC than that specified on the Certificate of Compliance (Form CF -1R). § 116(a)4: Fenestration products (except field -fabricated windows) have a label listing the certified U -Factor, certified Solar Heat Gain Coefficient (SHGC), and infiltration that meets the requirements of § 10-111(a) �§ 117: Exterior doors and windows weather-stripped; all joints and penetrations caulked and sealed. I IIIgSTALILA IGN C EIIBTERCAT E CIF -6R -]ENV -01 Envelope — Innsun aflonn9 Rooflm 9 IFennestirafnoan (bags 3 of 3) Site Address: Enforcement gen y: Permit Number: DECLARATION STATEMENT u I certify under penalty of perjury, under the laws of the State of Califomia, the information provided on this form is true and correct. a I am eligible under Division 3 of the Business and Professions Code to accept responsibility for construction, or an authorized representative of the person responsible for construction (responsible person). u I certify that the installed features, materials, components, or manufactured devices identified on this certificate (the installation) conforms to all applicable codes and regulations, and the installation is consistent with the plans and specifications approved by the enforcement agency. e I reviewed a copy of the Certificate of Compliance (CF -IR) form approved by the enforcement agency that identifies the specific requirements for the installation. I certify that the requirements detailed on the Cr -1R that apply to the installation have been met. 0 1 will ensure that a completed, signed copy of this Installation Certificate 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. II understand that a signed copy of this Installation Certificate is required to be included with the documentation the builder provides to the building owner at occupancy. Company Name: (Installing Subcontractor or General Contractor or.Builder/Owner) Responsible Person's Name: Responsible Person's Signature: CSLB License: Date Signed: Position With Company (Title): INSTALLATION CERTIFICATE CF -6R -LTG -01 Residential Lighting (Page 1 of 3 Site Address: Enforcement Agency: Permit .Number: %8757/ 1. Kitchen Lighting nnes nrniect incinde kitchen lighting? XXcs, complete section 1 ❑ No, go on to section 2 es §150(k-)3: The wattage of permanently installed luminaires (lighting fixtures has been determined as specified by §130(d)--- 0 130 d .❑ Yes ;R240 §1 50(k)3: In the kitchen, are there electrical boxes finished with a blank cover or where no electrical equipment has been installed, and where the electrical box can be used for a luminaire or a surface mounted ceiling fan? If yes, the following row must also be es: ❑ Yes JMNA Wattage has been calculated as 180 watts of low efficacy lighting er blank electrical box. §150(k)8 Kitchen Lighting must comply with either method (a), (b), or (c) below: (a) All high efficacy luminaires X,Yes, complies because only higb efficacy luminaires have been installed in the kitchen. ❑ No, complies with method b or (c). (b) > 50% watts used by high efficacy luminaires ❑ Yes, complies because at least 50°/a of the installed watts are from permanently installed high efficacy luminaires as demonstrated in the table below: 'Total A ?:Total B. ❑ No, complies with method (a) or (c). Fill out the following table if complying with either method (b) or (c). 'fable (b) (c) Additional Kitchen Low Efficacy Lighting ❑ Yes, complies because the kitchen lighting qualifies for additional low efficacy lighting and as demonstrated in table in (b) (above) and the table in (e) (below) that ( A + C ) > B ❑ No, complies with method (a) or (b). Additional kitchen low efficacy lighting is available only if all of the following are true: ❑ Yes. All low efficacy luminaires in the kitchen are controlled by a vacancy sensor Dimmer energy management control system (FMCS) or a multi -scene programmable control system. ❑ Yes. Permanently installed luminaires in garages laundry rooms closets greater than 70 square feet and utility rooms are high efficacy luminaires AND are controlled by a vacancy sensor. 'fable (c) Use 50 W for dwelling units _< 2,500 If From the Table in Use 100 W for dwelling units > 2,500 f Efficacy Yes/No ? A B C A+C Is (A+C) >B? Luminaire Type High Low Watts x Quantity High Efficacy Watts or Low Efficacy Watts ❑ ❑ x = or ❑ ❑ x = or ❑ ❑ x = or ❑ ❑ x = or ❑ ❑ x = or Compfies with method (b) if A > B Total: A: > B: (c) Additional Kitchen Low Efficacy Lighting ❑ Yes, complies because the kitchen lighting qualifies for additional low efficacy lighting and as demonstrated in table in (b) (above) and the table in (e) (below) that ( A + C ) > B ❑ No, complies with method (a) or (b). Additional kitchen low efficacy lighting is available only if all of the following are true: ❑ Yes. All low efficacy luminaires in the kitchen are controlled by a vacancy sensor Dimmer energy management control system (FMCS) or a multi -scene programmable control system. ❑ Yes. Permanently installed luminaires in garages laundry rooms closets greater than 70 square feet and utility rooms are high efficacy luminaires AND are controlled by a vacancy sensor. 'fable (c) Use 50 W for dwelling units _< 2,500 If From the Table in Use 100 W for dwelling units > 2,500 f Add Yes/No ? A B C A+C Is (A+C) >B? 2. Lighting Internal to Cabinets Does project includes lighting internal to cabinets? ❑ Yes complete section 2 ❑ No, go on to section 3 0 Yes. 6150(k)9: Permanentiv installed liehtina internal to cabinets uses < 20 watts of Dower Der linear foot of illuminated cabinet. INSTALLATION CERTIFICATE CF-6R-LTG01 Residential Lighting (Page 2 of 3 Site Address: �. EnforcementAgency: Permit Number: 3. Installed Devices and .Components Have Been Certified to the Energy Commission Does the proiect include any of the devices or components listed below?des, complete section 3 ❑ No, go on to section 4 1KYes §119 and §150(k)7(F): Any of the following devices and components which have been installed have been certified to the Energy Commission according to the applicable provisions of § 119: All LED lighting systems that are classified as high efficacy, ballasts used in recessed luminaires, vacancy sensors (automatic off/manual on occupant sensors), dimmers, track lighting integral current limiters, and outdoor motion sensors. 4. Lighting Controls Comulete section 4 J9 Yes ❑ NA § I50(k)7A: Permanently installed low efficacy luminaires are controlled by switches separate from those controlling high efficacy luminaires. 15 -Yes ❑ NA § 150(k)7B: Exhaust fans with integral lighting systems are switched separately from lighting systems, OR have a lighting system that can be manually turned on and off while allowing the fan to continue to operate for an extended period of time. Yes ❑ NA §150(k)7C: All permanently installed luminaires are switched with readily accessible controls that permit the luminaires to be manually switched on and off. Or -Yes ❑ NA § 150(k)7D: All lighting controls have been installed in accordance with the manufacturer's instructions. Yes ❑ NA § 150(k)7E: All lighting circuits that arc controlled by more than one switch, where a dimmer or vacancy sensor has been installed to comply with §150(k), no controls bypass the dimmer or vacancy sensor functions. g. Luminaires (.Lighting Fixtures) Does the nroieet include the installation of anv luminaires (indoor or outdoor)? 3KYes, complete section 5 ❑ No, go on to section 6 S( -Yes, high efficacy luminaire classification has been determined according to §150(k)l, and low efficacy luminaire classification has been determined according to §150(k)2. Ci(Yes ❑ NA § 150(k)4: Fluorescent lamps rated 13 watts or greater have an electronic ballasts having an output frequency no less than 20 kHz. ❑ Yes ACNA § 150(k)5: Permanently installed night lights, and night lights integral to permanently installed luminaires or exhaust fans, contain only high efficacy lamps meeting the minimum efficacies contained in Table 150-C and do not contain a Gne-voltage socket or line voltage lamp holder, OR the night light is rated to consume no more than 5 watts of power and does not contain a medium screw -base socket. Yes ❑ NA § 150(k)6: Lighting integral to exhaust fans, in rooms other than kitchens, meet the applicable requirements of § 150(k). ❑ Yes JR�NA Any electrical box finished with a blank cover or where no electrical equipment has been installed, and where the electrical box can be used for a luminaire or a surface mounted ceiling fan, has been treated as low efficacy luminaires for compliance with §150(k). Does the project include any luminaires that are recessed into insulated ceilings? Yes, complete the rest of section 5 ❑ No, go on section 6 Yes, §150(k)12: Luminaires that are recessed into insulated ceilings meet all of the following conditions: Yes, are listed, as defined in §101, for zero clearance insulation contact (IC) by UL or other nationally recognized testing/rating laboratory, and X -Yes, have labels that certify the luminaires are airtight with air leakage less than 2.0 CFM at 75 Pascals when tested in accordance with ASTM E283 (Exhaust fan housings are not required to be certified airtight), and X.Yes, are sealed with a gasket or caulk between luminaire housings and the ceiling, and all air leak paths between conditioned and unconditioned spaces have been sealed with a gasket or caulk. (including all exhaust fan housings), and Yes, allows ballast maintenance and replacement to be readily accessible to building occupants from below the ceiling without requiring the cutting of holes in the ceiling. 6. Indoor ]Lighting (any indoor room that is not a kitchen) lioes the project mcmae permancinty mstauea tummarres in an.room inat is not a xrtcnenc &i'es, complete section 6 ❑ No, go on to section 7 Yes ❑ NA § 150(k)10: Permanently installed luminaires in bathrooms, garages, laundry rooms, closets> 70 ft', and utility rooms are high efficacy luminaires OR are controlled by a vacancy sensor. es ❑ NA §150(k)ll: Permanently installed luminaires located in rooms or areas other than in kitchens, bathrooms, garages, laundry rooms, closets, and utility rooms are high efficacy luminaires, OR are controlled by a dimmer switch. OR are controlled by a vacancy sensor. INSTALLATION CERTIFICATE CF-6R-LTG01 Residential Lighting (Page 3 of 3 Site Address: Enforcement Agency: Permit Number: 7. Outdoor Lighting Does the oroicet include anv permanently installed outdoor lighting? Xi;, complete section 7 ❑ No, go on to section 8 Yes ❑ NA §150(k)13: Luminaires providing outdoor lighting, including outdoor lighting for private patios on low-rise residential buildings CSLB License: with four or more dwelling units, entrances, balconies, and porches, and which are permanently mounted to a residential Position With Company (Title): building or to other buildings on the same lot are high efficacy luminaires OR are controlled by a manual on/off switch, plus a motion sensor not having an override or bypass switch that disables the motion sensor, plus one of the following three additional control methods: a. A photocontrol that does not have an override or bypass switch that disables the photocontrol; or b. An astronomical time clock not having an override or bypass switch that disables the astronomical time clock, or C. Energy management controls systems (EMCs) not having an override or bypass switch that allows the luminaire to be always on. XYes ❑ NA Exception 2: Low efficacy outdoor luminaires used to comply with Exception l to §150(k)13 are controlled by an override switch which temporarily bypasses the motion sensing function, and the motion sensor is automatically reactivated within six hours. The luminaire is controlled by a photocontrol, astronomical time clock, or EMCS as required by Exception Ito §150(k)13. ❑ Yes �MCNA Exception 3: There are permanently installed luminaires in or around swimming pools, water features, or other locations subject to Article 680 of the California Electric Code which do not need to be high efficacy luminaires. ❑ Ye�NA §I50(k)14: Internally illuminated address signs comply with §148, OR do not contain a screw -base socket and consume no more than 5 watts of power as determined according to § 130(d). ❑ Yes AKA §150(k)15 Lighting for parking lots and carports with a total of 8 or more vehicles per site have lighting that complies with § 130,132, 134, and 147. Lighting for parking garages for 8 or more vehicles comply with § 130, 131, 134, and 146. If yes, the Nonresidential compliance forms must be submitted 8. Common areas of low-rise residential buildings Does the project include the installation of any luminaires in common areas of low-rise residential buildings? ❑ Yes, complete section 8 �No, go on to section 9 ❑ Yes, §1 50(k)) 6: Permanently installed lighting in the enclosed, non -dwelling spaces of low-rise residential buildings with four or more dwelling units shall be high efficacy luminaires OR are controlled by occupant sensor(s) certified to comply with §I 19(d). DECLARATION STATEMENT o I certify under penalty of perjury, under the laws of the State of California, the information provided on this form is true and correct. o 1 am eligible under Division 3 of. the Business and Professions Code to accept responsibility for construction, or an authorized representative of the person responsible for construction (responsible person). o I certify that the installed features, materials, components, or manufactured devices identified on this certificate (the installation) conforms to all applicable codes and regulations, and the installation is consistent with the plans and specifications approved by the enforcement agency. o I reviewed a copy of the Certificate of Compliance (CF -1 R) form approved by the enforcement agency that identifies the specific requirements for the installation_ I certify that the requirements detailed on the CF -1R that apply to the installation have been met. © 1 will ensure that a completed, signed copy of this .installation Certificate 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 signed copy of this Installation Certificate is required to be included with the documentation the builder provides to the building owner at occupancy. Company Name: (Installing Subcontractor or General Contractor or Builder/Owner) Responsible Person's Name: Responsible Person's Signature: CSLB License: Date Signed: Position With Company (Title): INSTALLATION C1ERT71CA7IE C F-6R-MECH-01 Domestic Hot MWater HW) (Page 1 of 2) Site Address:. Enforcement Agency: Permit Number: 1. WATER HEATING SYSTEMS: Heater Type CEC Certified Mfr Name & Model Number Distribution Type (Std, Point -of- Use, etc If Recirculation, Control Type # of Identical Systems Rated Input ^ or1 Btulhr) Tank Volume (allons) Efficiency (EF,, RE) Standby Los (%) ff .Note 1: For small gas storage (rated input less than or equal to 75, 000 Btu/hr), electric resistance and heat pump water heaters, list Energy Factor (EF). For large gas storage water heaters (rated input of greater than. 75, 000 Btu/hr), list Recovery Eff ciency (RE), Thermal Efficiency, Standby Loss and Rated Input. For instantaneous gas water heaters, list the Thermal Efficiency and Rated Input. 2. Mandatory Measures TO COMPLY - ALL ]BOXES DIST ]RE CHECKED §110-§113: Water heaters, showerhead and faucets are certified by the California Energy Commission. § 1500): Water System Pipe and Tank Insulation. And Cooling Line Insulation 1. Storage tank insulation A. Storage gas water heaters rated with an Energy Factor no greater than the federal minimal standard are externally wrapped with insulation having an installed thermal resistance of R-12 or greater; and B. Unfired storage tanks or other indirect hot water tanks have R-12 external insulation or R-16 internal insulation where the internal insulation R -value is indicated on the exterior of the tank. 2. Water piping and cooling system line insulation thickness and conductivity First 5 feet of hot and cold water pipes closest to water heater tank, non -recirculating systems, and entire length of recirculating sections of hot water pipes are insulated per Standards Table 150-B; and Pipe insulation for steam hydropic heating systems or hot water systems >15 psi, meets the requirements of Standards Table 123-A. Insulation is protected from damage, including that due to sunlight, moisture, equipment maintenance, and wind. § 15l(f)8D: If indicated on the CF -1.R, all hot water piping that runs from the hot water source to the kitchen fixtures is insulated per Standards Table 150-B. 1041A , --- r.,,,.,«.. 4,,,,.,.,.111410 IIl\`ISTA.LLATII.ON CER'Il E FIICAT E CF-611-MECH[-01 Domestic Hot Water ()[DIE W) (Hage 2 of 2) Site Address: Enforcement Agency: I Permit Number: � 3. Central Water )~Beating in Buildings with Multiple Dwelling Units (required for prescriptive) TO COMPLY - ALL BOXES MUST BE CHECKED All hot water piping in main circulating loop is insulated to requirements of § 1500) Central hot water systems serving six or fewer dwelling units which have (1) less than 25' of distribution piping outdoors; (2) zero distribution piping underground; (3) no recirculation pump; and (4) insulation on distribution piping that meets the requirements of Section 1500) Central hot water systems serving more than b dwelling units - presence of either a time control or a time/temperature control DECLARATION STATEMENT o I certify under penalty of perjury, under the laws of the State of California, the information.provided on this form is true and correct. o I. am eligible under Division 3 of the Business and Professions Code to accept responsibility for construction, or an authorized representative of the person responsible for construction (responsible person). o I certify that the installed features, materials, components, or manufactured devices identified on this certificate (the installation) conforms to all applicable codes and regulations, and the installation is consistent with the plans and specifications approved by the enforcement agency. 0 1 reviewed a copy of the Certificate of Compliance (CF -1R) form approved by the enforcement agency that identifies the specific requirements for the installation. I certify that the requirements detailed on the CF -1R that apply to the installation have been met. o I will ensure that a completed, signed copy of this Installation Certificate 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 signed copy of this Installation Certificate is required to be included with the documentation the builder provides to the building owner at occupancy. Company Name: (Installing Subcontractor or General Contractor or Builder/Owner) Responsible Person's Name: Responsible Person's Signature: CSLB License: Date Signed: Position With Company (Title): 1nnn ,.„,.,, c,........ ,:,.,..,..f ')nnn INSTALLATION C1Ell TIIMCAT E CF-6R-MIEC)Hf-05 ffndoor Air Quality and Mechanical Ventilation (Page 1 of 5) Site Address: F"forcement Agency: Permit Number. Ventilation for Indoor Air Quality (IAQ): All dwelling units shall meet the requirements of ANSPASHRAE standard 62.2. Ref: Title 24 Part 6 Section 150(0). Equation and table numbering on this CF -6R corresponds to the numbering for that information in the published ASHRAE Standard 62.2. WH®LF,BUIfL➢DING V1ENMATION Ventilation Rate: A mechanical supply system, exhaust system, or combination thereof shall provide whole -building ventilation with outdoor air each hour at no less than the rate in equation 4.1 a. For dwelling occupant densities known to be greater than (Nb, + 1), the rate shall be increased by 7.5 cfin for each additional person. Where: Enter Eq 4.1a Calculation: (Eq. 4.1a) Qfm = 0.0lAn�r+ 7.5(Nb<+ 1) Afl�, = conditioned floor area, fl2 A,O, _ ' Nb, = number of bedrooms; not to be less than one Nbr = Qom° = ventilation air requirement = fan flow rate, (cfm) Qf" = ,fes %3 )[Delivered Ventilation: The effective ventilation rate of an intermittent system is the combination of its delivered capacity, its fractional on-time, cycle time, and the ventilation effectiveness from Table 4.2. This calculation only applies to intermittent systems. Where: Enter Eq 4.2 Calculation Q, = ventilation air requirement from Fq. 4.1 a (above) (if applicable). (Eq. 4.2) Qf = Q, / (sf) f = daily fractional on-time, (%) Ql _ c = ventilation effectiveness (from Table 4.2) f Qf = fan flow rate during the on -cycle (cfm) e Qf = 'fable 4.2 — Ventilation Effectiveness for Intermittent Fans Daily Fractional On -Time, f Ventilation effectiveness, e f <_ 35% 0.33 35%<f <60% 0.50 60%< f < 80% 0.75 s0%:!< f 1.0 Fan runs at least once every three hours 1.0 Whole -Building Ventilation Rate Summary Select the method used to provide Whole - Building Ventilation and enter the required fan flow rate (chn). Select one: IELContinuous fan flow (cfm) ❑ Intermittent fan flow (cfm) _ Use the fan flow rate from this summary for selection of the whole -building ventilation fan and for the duct design for the whole -building ventilation system. Provide the system design information in applicable sections below. LOCAL VENTILATION EXHAUST Local mechanical exhaust fans shall be installed in each kitchen and bathroom. Ibe minimum airflow rates shall be at least the amount indicated in tables 5.1 and 5.2. 'fable 5.1 Table 52 Intermittent TA)ral Ventilation Exhaust Airtlow Rates Continuous Local Ventilation Exhaust Airflow Rates Application Airflow Notes Application Airflow Notes Vented range hood Based on Kitchen Kitchen 100 cfm required if exhaust fan Kitchen 5 ACH flow is less than 5 ACH Volume Bathroom 50 cfm Bathroom 20 cfm 7nnQ 1:'.,..,, A........r 7nn0 INSTALLATION CERTIFICATE CF-611-MECH-05 Indoor Air Quality and Mechanical Ventilation (Page 2 of 5) Site Address: Enforcement Ar--.- Permit Number: VENTILATION SYSTEM DESIGN — Fan selection and duct design criteria for compliance The airflow rates required refer to the delivered airflow of the system as installed and tested using a flow hood, flow grid, or other airflow measuring device. Alternatively, the airflow rating at a pressure of 0.25 in. w.c. of a certified fan may be used to demonstrate compliance without testing of the airflow of the installed system, provided the system duct siting meets the prescriptive requirements of Table 7.1, or manufacturer's design criteria. Other methods may be used to provide the required ventilation rates when approved by a licensed design. professional, subject to confirmation of delivered ventilation airflow of the installed system. Central Fan Integrated (CFI) ventilation systems shall demonstrate compliance byfield testing of the delivered ventilation airflow of the installed system. WHOLE -BUILDING VENTILATION SYSTEM DESIGN - Identify the ventilation system design criteria (select one criteria from this column) Requirements for installer to demonstrate compliance with Airflow Test code Required? Enter the installed ventilation air -moving equipment information and the installed ventilation duct system Prescriptive design (Table 7.1) information in the tables below, and certify on the CF -6R that no the installed system conforms to the Table 7.1 prescriptive design criteria. Central forced air system fans used in Central. Fan Integrated ventilation systems shall demonstrate, in air distribution mode, ❑ Central Fan Integrated (CFI) a watt draw less than 0.58 W/CFM per Standards § 151(f)l 1. yes Submit a CF-6R-MECH-22-HERS form for each forced air unit used for a CFI system. HERS verification is required. Enter the installed ventilation air -moving equipment information and the installed ventilation duct system ❑ Engineered Design information in the tables below, and certify on the CF -6R that yes the installed system conforms to the engineered ventilation system design approved by the enforcement agency. Enter the installed ventilation air -moving equipment information and the installed ventilation duct system ❑ Manufacturer's design criteria information in the tables below, and certify on the CF -6R that no the installed system conforms to the manufacturer's ventilation system duct design criteria. LOCAL VENTILATION SYSTEM DESIGN - Identify the ventilation system design criteria (select one criteria from this column) Requirements for installer to demonstrate compliance with Airflow Test code Required? Enter the installed ventilation air -moving equipment information and the installed ventilation duct system R[Prescriptive design (Table 7.1) information in the tables below, and certify on the CF -6R that no the installed system conforms to the Table 7.1 prescriptive design criteria. Enter the installed ventilation air -moving equipment information and the installed ventilation duct system ❑ Engineered Design information in the tables below, and certify on the CF -6R that yes the installed system conforms to the engineered ventilation system design approved by the enforcement agency. Enter the installed ventilation air -moving equipment information and the installed ventilation duct system ❑ Manufacturer's design criteria information in the tables below, and certify on the CF -6R that no the installed system conforms to the manufacturer's ventilation system duct design. criteria. INSTALLATION CERTIFICATE CF-6R-MECH-05 Indoor Air Oualitv and Mechanical Ventilation (Page 3 of 5)� Site Address: Enforcement Agency: Permit Number: Table 7.1 Prescriptive Duct Sizing Requirements System Diameter, in Flex Duct Smooth Duct Fan Rating cfrn 0.25 in. w.. 50 80 100 125 50 80 100 125 Maximum Allowable Duct Length (ft) Certified Diameter, in Flex Duct Smooth Duct 3 X X X X 5 X X X 4 70 3 X X 105 35 5 X 5 NL 70 35 20 NL 135 85 55 6 NL NL 125 95 NI, NI, NL 145 7 and above NT NL NL NL NL NL NL NL This table assumes no elbows. Deduct 15 ft of allowable duct length for each turn, elbow, or fitting. Interpolation and extrapolation in Table 7.1 is not allowed. For airflow values not listed, use the next higher value. This table is not applicable for airflow > 125 cfm. NL = no limit on duct length of this size. X = not allowed, any ten of duct of this size with assumed turns, elbows, fittings will exceed the rated pressure drop. INSTALLED VENTILATION AIR -MOVING EQUIPMENT INFORMATION Ventilation devices and equipment .shall be tested and rated by HVI procedures for airflow and sound. Sound rating maximum is 1.0 sone for all continuous dutyfans; 1.0 sone for intermittent duty whole -building fans; and 3.0 sone for intermittent duty local exhaust fans. Refer to the Residential Compliance Manual section 4.6 for information about exclusions to these sound rating requirements. In the table below, list the fan equipment installed that meets the requirement for whole-buildine ventilation and local ventilation exhaust. Fan or System Fan Power System Type2 Required Fan Certified Sound Ratio Name or (WBV Airflow' Manufacturer Fan Airflow6 Rating? Fan (Watt per Location' or LVE) Name° Model Numbers . CFM (Sone) Watts e CFN4)9 p(CFM) ( 15c) ,.I p l 1) Enter the Fan or System Identification Name or Location Name or System Identifier (e.g. "Bath02" "MastBath ", "Kitchen0l 2) What type of ventilation requirement is the fan specified to meet? WBV (whole -building ventilation) or LVE (local ventilation exhaust). 3) Enter the required ventilation airflow values determined by the calculations or tables in the WHOLE -BUILDING VENTILATION and/or LOCAL VENTILATION EXHAUST sections at the beginning of this Installation Certificate (CFM). At least one fan must be designated for use for compliance with the "Whole -Building Ventilation" requirement. 4) Enter the fan manufacture's name. 5) Enter the fan model number or series number. 6) Enter the fan's Certified Airflow rating at 0.25 inch w.c. (CFM). Facts rated at less than 025 inch w.c. (e.g. 0.1 inch w.c.) cannot be used to comply with the ventilation requirements using the prescriptive design criteria in Table 7.1. This certified airflow rating value must be equal to or greater than the required airflow from column 3 of this,table when demonstrating compliance using Table 7.1. 7) FAter the fan's certified sound rating (Sone) 8) Enter the fan watt draw 9) Divide the Watt value from column 8 by the Certified Airflow value (CFM) from column 6. For dwellings utilizing the performance energy compliance method, for standalone whole -building ventilation systems (does not apply to local ventilation exh uu.st fans), the an power ratio must be less than orequal to the fan power ratio value reported on the Performance CF -1 R. onnu n r ..: r r . t: V,.- n 1.,....1, 'M7/1 INSTALLATION CERTIFICATE CF -6B -INCH -05 Indoor Ain- Quality and Mechanical Ventilation (&" e 4 of 5) Site Address:Enforcement Agency: Permit Number: T 2v �o INSTALLED VENTILATION DUCT SYSTEM INFORMATION Airflows required by the standard refer to delivered airflow of the installed system as determined by testing with a flow hood,,flow grid, or other measuring device, Alternatively, the installed equipment's HVI airflow rating at a pressure of 0.25 inch w.c. may be used, provided the system can he inspected to confirm the duct sizing meets the prescriptive requirements of Table 7.1, or manufacturer's duct design criteria Fan or System Name or Locations Compliance Method2 T; P; or Required Airflow; CF Airflow Test° (CFM) Duct "I' e5 Number of Elbows and Fittin s6 Actual Duct Length' ft Allowable Duct Length' ft Pass or Fail9 1. Enter the Fan or System Identification Name, or Location Name, or System Identifier. These should be the same identifiers as shown in the INSTALLED VENTILATION AIR -MOVING EQUIPMENT INFORMATION table column I above. 2. Enter the method for demonstrating compliance with the ventilation airflow requirements. Enter "T" for Tested; "P" for Prescriptive Table 7,1 design criteria (inspection); "M" for Manufacturer's duct design criteria (inspection). Note: the building official may require submittal of manufacturer's published design criteria documentation if compliance it to be demonstrated by inspection of the installationfor conformance to manufacturer's design criteria. 3. Enter the required ventilation airflow values determined by the calculations or tables in the WHOLE -BUILDING VENTILATION and/or LOCAL VENTILATION EXHAUST sections at the beginning of this Installation Certificate (CFM). These should be the same airflow values that were entered for each corresponding fan in column 3 of the INSTALLED VENTILATION AIR -MOVING EQUIPMENT INFORMATION table above. 4. !f complying by a method that requires an Airflow Test of the installed system, enter the result from the Airflow Test for the installed system (CFM). S. Enter duct type for the installed system. Choices are "Flex" or "Smooth" if using Table 7.1 for compliance. 6. Enter total number of elbows or fittings or abrupt turns in the ventilation duct for the installed system. 7. Enter the installed system's actual total duct length (ft). 8. If complying by use of the prescriptive design criteria or manufacturer's design criteria, enter the Maximum Allowable Duct Length (ft), for the system as determined by Table 7.1 or manufacturer's duct design criteria. 9. If complving by airflow test, the system passes if the Tested Airflaw4 equals or exceeds the Required Airflow3. If complying by demonstrating conformance to prescriptive design criteria or manufacturer's design criteria, the system passes if actual total duct lengthfrom column 7 is less than the maximum allowed lengthfrom column 8. Enter: Pass or Fail I Indoor Air Ounality and Mechanical Ventilation (]Page 5 of 5) 1 Site Address: Enforcement Agency: Permit Plumber: 18-7;5 j .._ `" �� Vi i - i OTHER REQUIREMENTS The items listed below (6.1 through 6.8) correspond to the information given in ASHRAE 622 Section 6 "Other Requirements". Refer also to Chapter 4.6 of the Residential Compliance Manual (Section 4.65) for information describing these "Other Requirements ". The signature of the Responsible Person in the declaration statement below certifies that the building complies with these requirements specified in ASHRAE 62.2 Section 6.1 through 6.8 if applicable. ❑ 6.1 Transfer Air ❑ 6.2 Instructions and Labeling ❑ 6.3 Cloths Dryers ❑ 6.4 Combustion and solid -fuel burning appliances ❑ 6.5 Garages ❑ 6.6 Ventilation Opening Area ❑ 6.7 Minimum filtration ❑ 6.8 Air Inlets Prescriptive Designs: For ventilation systems that utilize prescriptive design criteria, the signature of the Responsible Person in the declaration statement below certifies that the installed system. conforms to the prescriptive ventilation system design criteria from Table 7.1 of Standard 62.2 and manufacturer's installation specifications. ❑ Engineered Designs: For ventilation systems that utilize engineered design criteria, the signature of the Responsible Person in the declaration statement below certifies that the installed system conforms to the engineered ventilation system design documentation approved by the enforcement agency. ❑ Manufacturer's design criteria: For ventilation systems that utilize manufacturer's design criteria, the signature of the Responsible Person in the declaration statement below certifies that the installed system conforms to the manufacturer's published duct system design criteria and installation specifications. DECLARATION STATEMENT • I certify under penalty of perjury, under the laws of the State of California, the information provided on this form is true and correct. • 1 am eligible under Division 3 of the Business and Professions Code to accept responsibility for construction, or an authorized representative of the person responsible for construction (responsible person). • I certify that the installed features, materials, components, or manufactured devices identified on this certificate (the installation) conforms to all applicable codes and regulations, and the installation is consistent with the plans and specifications approved by the enforcement agency. • 1 reviewed a copy of the Certificate of Compliance (CF -IR) form approved by the enforcement agency that identities the specific requirements for the installation. I certify that the requirements detailed on the CF- IR that apply to the installation have been met. I will ensure that a completed, signed copy of this Installation Certificate 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. 1 understand that a signed copy of this Installation Certificate is required to be included with the documentation the builder provides to the building owner at occupancy. Company Name: (Installing Subcontractor or General Contractor or Builder/Owner) Responsible Person's Name: Responsible Person's Signature: CSLB License: Date Signed: Position With Company (Title): n INSTALLATION CERTIFICATE CF-6R-MECH-041 Space Conditioning Systems, Ducts and ]Fans (Page 1 of B) Site Address: ]Enforcement Agency: Permit Number: -Too Space Condifio>m ng Systems Ideating Equipment Equip Type (package- heat um F:L) CEC Certified Mfr. Name and Model Number y-�A1 ARI Reference Number 2 # of Identical Systems Efficiency (AFUE, etc,)1,3 (>_CFAR value a Duct Location (attic, crawl- space, etc.) Duct R -value Heating Load Btu/br(Btu/hr) Heating Capacity r7 q 60 P Cooling Equipment Equip Type (package heat um CEC Certified Mfr. Name and Model Number ARI Reference Number 2 # of Identical stems Efficiency (SEER and EER) 1,3 (>_CF -1R Value)° Duct Location (attic, crawl- space, etc. Duct R,alue Cooling Load Btu/hr) Cooling Capacity Btu/br) P 1. If project is new construction, see Footnotes to Standards Table 151-B and Table 151-C for duct ceiling alternative compliance. 2. ARI Reference Number can be found by entering the equipment model number at http: //www. aridirectory. orglari/ac php# 3. Listed efficiency on this page must be greater than or equal (>_) to the value shown on the CF -1 R form. 4. When CF -IR is reference it is also applicable to the CF -IR, CF -IR -AA or CF -JR -ALT ALL BOXES MUST BE CHECKED TO BE A VALID FORM § 110-§ 113: HVAC equipment is certified by the California Energy Commission. �§ 150(h): Heating and/or cooling loads calculated in accordance with ASHRAE, SMACNA, or ACCA. §I50(i): Setback Thermostat on all applicable heating and/or cooling systems meet the requirements of §112(c). 92�§ 1500)2: Pipe insulation for cooling system refrigerant suction, chilled water and brine lines meets minimum requirements of Table 150-B and includes a vapor retardant or is enclosed entirely in conditioned space. *1nnu n,...;,a,.—t;,a r i; )7,.,...... 'nnn INSTALLATION CERTIFICATE CF-6R.M ECH-04 Space Conditioning S stems, Ducts and ]Fauns (Page 2 of 2) Site address: i ]Enforcement agency: ]Permit ]Number: Ducts and Fans §150(m): Duct and Fans 1. All air -distribution system ducts and plenums installed, sealed and insulated to meet the requirements of CMC Sections 601, 602, 603, 604, 605 and Standard 6-5; supply -air and return -air ducts and plenums are insulated to a minimum installed level of R4.2 or enclosed entirely in conditioned space. Openings shall be sealed with 'mastic, tape or other duct -closure system that meets the applicable requirements of Ut,181, UI.. 181A, or UL 181 B or aerosol sealant that meets the requirements of UL 723. if mastic or tape is used to seal openings greater than 1/4 inch, the combination of mastic and either mesh or tape shall be used; and �-- I. Building cavities, support platforms for air handlers, and plenums defined or constructed with materials other than sealed sheet metal, duct board or flexible duct shall not be used for conveying conditioned air. Building cavities and support platforms may contain ducts. Ducts installed in cavities and support platforms shall not be compressed to cause reductions in the cross-sectional area of the ducts. Z_ 2D. Joints and seams of duct systems and their components shall not be sealed with cloth back rubber adhesive duct tapes unless such tape is used in combination with mastic and draw bands. RLT Exhaust fan systems have back draft or automatic dampers. a 8. Gravity ventilating systems serving conditioned space have either automatic or readily accessible, manually operated dampers. R- 9. Protection of Insulation. Insulation shall be protected from damage, including that due to sunlight, moisture, equipment maintenance, and wind. Cellular foam insulation shall be protected as above or painted with a coating that is water retardant and provides shielding from solar radiation that can cause degradation of the material. 10. Flexible ducts cannot have porous inner cores. DECLARATION d STATEMENT o I certify under penalty of pequry, under the laws of the State of California, the information provided on this form is true and correct. o I am eligible under Division 3 of the Business and Professions Code to accept responsibility for construction, or an authorized representative of the person responsible for construction (responsible person). o I certify that the installed features, materials, components, or manufactured devices identified on this certificate (the installation) conforms to all applicable codes and regulations, and the installation is consistent with the plans and specifications approved by the enforcement agency. o I reviewcd a copy of the Certificate of Compliance (CF -IR) form approved by the enforcement agency that identifies the specific requirements for the installation. I certify that the requirements detailed on the CFAR that apply to the installation have been met. o l will ensure that a completed, signed copy of this Installation Certificate 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 signed copy of this Installation Certificate is required to be included with the documentation the builder provides to the building owner at occupancy. .......... Company Name: (Installing Subcontractor or General Contractor or Builder/Owner) Responsible Person's Name: Responsible Person's Signature: CSLB License: Date Signed: Position With Company (Title): InnQ n­;.r,..,i;,,r >;,.,., e..,,,..., Inn()