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14040122
CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10540 CHACE DR CONTRACTOR: ASAO ICHIRO AND PERMIT NO: 14040122 AKEMI OWNER'S NAME: ASAO ICHIRO AND AKEMI 10540 CHACE DR DATE ISSUED: 07/03/2414 OWNER'S PHONE: 4087399923 CUPERTINO, CA 95014-1061 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL E] COMMERCIAL CONSTRUCT ADDITION (184 SQ FT); COMPLETE License Class Lic. N INTERIOR REMODEL (2,590 SQ FT); RELOCATEXPGRADE MAIN Contractor Date ELECTRICAL PANEL (200 AMP); RE -ROOF (3094 SQ FT). I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain a certificate of consent to self -insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the Sq. Ft Floor Area: Valuation: $300000 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: 32613027.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct. 1 agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS O IT 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 indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the 180 DAYS ALLED INSPECTION. .n._ j 3 granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section r -" 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 l 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. 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 I store or handle hazardous 1 have and will maintain a Certificate of Consent to self -insure for Worker's material. Additionally, should I use equipment or devices which emit hazardous Compensation, as provided for by Section 3700 of the Labor Code, for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued, will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Sections 25505, 25533, and 25534. Section 3700 of the Labor Code, for the performance of the work for which this ---_ �r Owner or authorized agent: Date: permit is issued. 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, 1 CONSTRICTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code, I 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. 1 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. Signatur&0_1� Date CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildingO cupertino.org CUPERTINO n NEW CONSTRUCTION n ADDITION n ALTERATION / TI n REVISION / DEFERRED �O h ORIGINAL PERMIT 4 PROJECT ADDRESS 1 C k Q, e APN N 26 — I'S _ 0 7 "� /C� OWNER NAME , 1 O 1 Cw\ d /�/ 1 II ' e & Q U PHONE O n �O _�9 � E-MAIL STREET ADDRESS ((, D CITY, STATE, ZIP CL4 LA Ct So/ 6 FAX C r e % AD CONTACT NAME hC41 war 1 6, PHONE �6 V- 24 �j ! S q 9L E-MAIL Ghk.� • �� t"'% C4 ^119 k. STREET ADDRESS I /nINJa V '4/-G Dr -CITY, STATE, ZIP 411tL10 C� ��0�11 I" ❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTORAGENT T E� ARCHITECT ❑ ENGL'\'EER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME �IL LICENSEN'UMBER LICENSETYPE BUS. LICK COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARCHITECT/ENGINEERNAME ^ I- n LL LICEIJSENUMBECi kUr LQ_ _T BUS. LIC N tAr /jam �I 1a ' r� .CO� COMPANY NAME j� e 4 Lj N)(A IZ E-MAIL FAX STREET ADDRESS 0 �` CITY, STATE, ZIP S'~ or p 51 2- S J���O�yJSC PHONE 407-264 - 41 c1D DESCRIP-PON OF WORK ( U D „,--/ jG I �t K11/ �%_ . (ZQmO� n _ k!�l� F�7 0�- / e o 'SEYLAC, W1175 3mPt 119 i(, LE) ce6v' DVI-NA'�lf _T_?L �"rn L EXISTING USE PROPOSED USE CONSTK TYPE k' STORIES l 2 USE TYPE OCC. SQ.FT. VALUATION ($) AREA � l () ` G p ' DEMO - TOTAL NET i62F1 `L BATHROOM REMODEL ARCS � I?- J c KITCHEN OTHER REMODEL AREA �z REMODEL AREA J PORCH k D AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH / r- 1 y ` -y ✓ I C ®ATTACH h.' DWELLING UNITS: IS IS A SECOND UNIT ❑ YES SECOND STORY ❑ YES i BEING ADDED? EDNO ADDITION? QNO PM -APPLICATION ❑YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YES £ICHLER HOME? ItEC ,y -- '� /r: TOTAL VALUATION: PLAN'N'INGAPPLk ONO PLANNING APPROVAL LETTER ❑NO By my signature below, I certify to each of the following: I am the property owner or authorized agent to a e r er's behalf. I have read this application and the information I have provided i correct. ave read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building c ructio . I uthorize representatives of Cupertino to enter the above-ide tified prop'er'ty for inspection purposes. Signature of Applicant/Agent: Date: M SUPPLEN4ENTAL 1NFORATION.REQUIRED w„ „? `'F A cI ZfIPE` ,k,.r, ® OVER AE-GOU$yTSR i r , x �X X � BLTIL,DING PLAN BE''t[EW, ` � r'4 t New SFD or Multifamily dwellings: Apply for demolitionpen-nit for existing building(s). Demolition permit is required prior to issuance of building permit for neva' building. P r>u rR,I•,SS,� +r r�r4 j�rl� �c^�!x'tx 11r GG�Y�PL^AA��nGYLf�NR>r�'1�wya ;y�a,Y„ Bldgs: Provide Hazardous Materials Disclosure C� Irl," —Commercial a completed Q s nAxTsrlr r r �%✓fix '�f i�'' ai+!" �i�i ,�y i !2i CUs I Woxx iti yf�)t !�, ���,�, a �a, i�r t �� G�ao r 1 � %' . form if any Hazardous Materials are being used as part of this project.,i,^Y+$ ®v LARGE �% l 9N,,�yyr�lf'"�,/f � x(y r �! F'IRF PE�'T1rs�rJd�iGx�kx �Ei�4�`x6�'�� f 1' ,. i�? ✓J�x ! i�,. Yh'I`JIYNI r�4�rtN ai'!.kY(l ,Id l'A T ,5,1 IP ik7 IA i (rl,+"t'+ _ Copy of Planning Approval Letter or Meeting with Planning prior to Copy s it 5+M' x is irij irAr J , vg,rf 91 SrtSx�RIyC9 r submirtal of Building Pen -nit application.G n,�rrr wnN }r l y r®kh,szxwarY iii +y + � (� .,��/ i ,f', a,••'tj + , .'r_;�,, .�` % ;,r'' D:,"ENIVYRONMENTAf.`HEAt,TP1 � ,°J�,c,�,;: BldgApp_201 Ldoc revised 06121111 PAik j LUQ' CITY OF CUPERTINO ISMI FEE ESTIMATOR - BUILDING DIVISION OCCUPANCY TYPE: ADDRESS: 10540 CHACE DR DATE: 04/18/2014 REVIEWED BY: MELISSA PC FEE ID APN: 326 13 027 BP#: �a v� "VALUATION: 1$300,000 PERMIT TYPE: Building Permit PLAN CHECK TYPE: Addition PRIMARY SFD or Duplex USE: 2nd Unit? 0 Yes No OTC? 0Yes No PENTAMATION PERMIT TYPE: 1R3SFDADD WORK ADD 184S.F. COMPLETE REMODEL OF E SFD (2,590 S.F. CHANGE ROOF LINE 7 N SCOPE SKYLIGHTS, 19 WINDOWS/DOORS, RELOCATE/UPGRADE TO 200AMP PANEL, RE -ROOF 34 0 OCCUPANCY TYPE: TYPE OF CONSTR. FLR AREA s.f. PC FEES PC FEE ID BP FEES BP FEE ID R-3 (Custom) II-B,III-B,IV,V-B 184 $1,059.00 IADDPLCK $1,026.00 IADDINSP $0.00 PME Plan Check: $0.00 200 amps $47.00 Electrical IBELEC200 Services Permit Fee: $1,026.00 Suppl. Insp. Fee:O Reg. 0 OT 0,0 hrs $0.00 3,400 s. f. $544.00 Re -roof IREROOFRES PME Unit Fee: $0.00 PME Permit Fee: $47.00 TOTALS: 184 $1,059.00 $1,026.00 MECH, HOURLY 0 Yes 0 No PLUMB, HOURLY 0 Yes 0 No ELEC, HOURLY 0 Yes 0 No Elec. Plan Check 0.0 1 hrs $0.00 Elec. Permit Fee: IEPERMIT Other Elec. Insp.0.0 hrs $47.00 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 hosed on the nreliminary information available and are onlv an estimate. Contact the Dent for addn'1 info. FEE ITEMS (Fee Resolution 11-053 Eft: 77'13) FEE QTY/FEE MISC ITEMS Plan Check Fee: $1,059.00 E5K s. f. $5,771.00 Remodel, Other IREMRES3 Suppl. PC Fee: 0 Reg. 0 OT 0,0 hrs $0.00 PME Plan Check: $0.00 200 amps $47.00 Electrical IBELEC200 Services Permit Fee: $1,026.00 Suppl. Insp. Fee:O Reg. 0 OT 0,0 hrs $0.00 3,400 s. f. $544.00 Re -roof IREROOFRES PME Unit Fee: $0.00 PME Permit Fee: $47.00 = # $2,926.00 Skylight ISKYL<10SF <= 10 S.f. C) 0 Work Without Permit? 0 Yes 0 No $0.00 Advanced Planning Fee: IPLLONGR $25.76 Select a Non -Residential Building or Structure 0 0 i Travel Documentation Fee: ITRAVDOC $47.00 Strong Motion Fee: IBSEISMICR $30.00 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $12.00 SUBTOTALS; $2,246.76 $9,288.00 TOTAL FEE: 1 $11,534.76 Revised: 04/01/2014 CUPERTINO CONTRACTOR / SUBCONTRACTOR LIST Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 Fax: 408-777-3333 *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: — - Signature Date Please check applicable subcontractors and complete the following information: 01' Owner / Contractor Signature Date SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing L / Carpeting ---Flooring Linoleum /Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile 01' Owner / Contractor Signature Date CUPERTINO OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 - building(d,)cupertino.orq Dear Property Owner(s): An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified at: SITE ADDRESS U ` _C 0 z� 7�z,6 BP# yv y�l ZZ 7 OWNER NAME AM,/2 OWNER � D SSZCL-ZZPZ S ` DESCRIPTION OF WORK: — 2 b ^L We are providing you with an Owner -Builder Acknowledgment and Information Verification Form to make you aware of your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner -Builder. We will not issue a building permit until you have read, initialed your understanding of each provision, signed, and returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION (DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information.) . I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner - Builder" building permit that erroneously implies that the property owner is providing his or her own labor and material personally. I, as an Owner -Builder, may be held liable and subject to serious financial risk for any injuries sustained by an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers on my property. ,2. I understand building permits are not required to be signed by property owners unless they are responsible for the construction and are not hiring a licensed Contractor to assume this responsibility. L013. I understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. A4. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. - sons other than Californialicensed Contractors and the total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer" under state and federal law. c6. I understand if I am considered an "employer" under state and federal law, I must register with the state and federal government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject me to serious financial risk. 7. 1 understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is performed under contract with a licensed general building Contractor. /20- I understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for any financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the workmanship or materials. OwnerBuilderForm 2010.doc revised 04/14/10 (. 1 understand I may obtain more information regarding my obligations as an "employer" from the Internal Revenue Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed contractors. i10. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the party legally and financially responsible for proposed construction activity at the site address listed above. 11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner -Builders as well as employers. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the *12. mation I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If you contract with someone who does not have a license, the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be in civil court, It is also important for you to understand that if an unlicensed Contractor or employee of that individual or firm is injured while working on your property, you may be held liable for damages. If you obtain a permit as Owner -Builder and wish to hire Contractors, you will be responsible for verifying whether or not those Contractors are properly licensed and the status of their workers' compensation insurance coverage. CONSTRUCTION LENDING AGENCY (DIRECTIONS: Please complete the following construction lending agency information.) I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec 3097 Civ.) Lender Name: Lender Address.- Before ddress: Before a building permit can be issued, this form must be completed and signed by the property owner and returned to the agency responsible for issuing the permit. Note: A copy of the property owner's driver's license, form notarization, or other verification acceptable to the city may b"quired to be presented when the permit is issued to verify the properfy owner's signature. Property Owner's Signature: i— Date: 7 -------------------------------------------------------------------------------------------------------------------------------------------- (NOTE: The following Authorization Form is required to be completed by the property owner only when designating an agent of the property owner to apply for a construction permit for the Owner -Builder). AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize the following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an Owner -Builder Permit for my project. Scope of Construction Project (or Description of Work): Project Location or Address: Name of Authorized Agent: Address of Authorized Agent: Tel No I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above information and certify its accuracy. Note: A copy of the property owner's driver's license, form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued to verify the property owners signature. Property Owner's Signature: Date: OwnerBuilderForn7 2010.doc revised 09/19/10 ICC -ES Evaluation Report ESR -2072 Ir issued September 1, 2013 This report is subject to' enewal September 1, 2015. www.icc-es.org 1 (800) 423-6587 (562) 699-0543 A Subsidiary of the International Code Council® DIVISION: 07 00 00—THERMAL AND MOISTURE PROTECTION Section: 07 21 00—Thermal Insulation Section: 07 25 00—Water-Resistive BarrierstWeather Barriers REPORT HOLDER: BAYER MATERIALSCIENCE, LLC 2400 SPRING STUEBNER ROAD SPRING, TEXAS 77389 (800) 226-3626 www.sof.bavermateriaiscience.ce EVALUATION SUBJECT: BAYSEALTM CLOSED CE POLYURETHANE FOAM INSULA' 1.0 EVALUATION SCOPE Compliance with the following codes: uS I g 2x14 PRAY -APPLIED 3.0 DESCRIPTION 3.1 BaysealTM" Closed Cell Foam Plastic Insulation: BaysealTM Polar Closed Cell spray -applied polyurethane foam insulation comprises a series of products designated: BaysealTM CC; BaysealTM CC Polar; BaysealTM CC X; and BaysealTM" CC XP. BaysealTM Closed Cell spray polyurethane foam insulation is medium -density polyurethane foam plastic intended to be installed as a component of floor/ceiling and wall assemblies. The material is a two -component, closed cell, one -to -one -by - volume spray foam insulation with a nominal density of 1.9 pcf (30 kg/m3). The insulation is produced in the field by combining a polymeric isocyanate (A component) with a polymeric resin blend (B component). The insulation liquid components have a shelf life of six months, are supplied in nominally 55 -gallon (208 L) drums and must be stored at temperatures between 70oF (21°C) and 80°F (27°C) a minimum of 48 hours prior to use. 3.2 Surface -burning Characteristics: The insulation at a maximum thickness of 4 inches ■ 2012 and 2009 International Building Codee (IBC) (102 mm) and a nominal density of 1.9 pcf (30 kg/m3) has ■ 2012 and 2009 International Residential Code ® (IRC) a flame -spread index of 25 or less and a smoke -developed ■ 2012 and 2009 International Energy Conservation index of 450 or less when tested in accordance with ASTM Code®(IECC) E84. Thicknesses of up to 8 inches (203 mm) for wall cavities and 12 inches (305 mm) for ceiling cavities are ■ Other Codes see Section ed based on room comer fire testingin Properties evaluated:CUPE ce with NFPA 286, when covered with a min mum Building iJt?�iaifi t6htck (13 mm) gypsum board or an equivalent ■ Surface -burning characte s, thermal barrier complying with, and installed in accordance ■ Physical properties A !a� with, the applicable code. ■ Thermal resistance _ 3.3 Thermal Resistance (R -values): ■ Attic and crawl space installatio M ion has thermal resistance (R -value) at a mean REVIEWED FOR CODE COM���tafl��l� ( ) ■ Air permeability te,mL,�rature of 75°F (24oC) as shown in Table 1. ■ Vapor permeance Rev!ewed By. �� 3:4'r Permeance: ■ Water -resistive barrier ■ Exterior walls in Types I through IV construction 2.0 USES BaysealTM Closed Cell spray foam insulation is used as thermal insulating materials in Type I, II, ill, IV and V construction under the IBC and dwellings under the IRC. See Section 4.6 for use in Type I, II, III and IV construction. The insulation is for use in wall cavities, floor assemblies or ceiling assemblies, or attics and crawl spaces when installed in accordance with Section 4.0. When installed in accordance with Section 4.5, the insulation may be used as an alternative to water–resistive barriers required in IBC Section 1404.2 and IRC Section R703.2. The foam plastic has a vapor permeance of less than 1 perm (5.7x10-" kg/Pa-s-m) when applied at a minimum thickness of 1 inch (25.4 mm) and may be used where a Class II vapor retarder is required by the applicable code. 3.5 Air Permeability: BaysealTM Closed Cell spray foam insulation is air - impermeable in accordance with Section R806.4 of the IRC, at a minimum thickness of 3/4 -inches (19.1 mm), based on testing in accordance with ASTM E283. 3.6 BaysealTM IC Intumescent Coating: BaysealTM IC intumescent coating is a one -component, water-based polymer coating. BaysealTM IC intumescent ICC -ES Evaluation Reports are not to be construed as representing aesthetics or any other attributes not specifically addressed, nor are they to be construed as an endorsement of the subject of the report or a recommendation for its use. !here is no warranty by ICC Evaluation Service, LLC, express or implied, as to any finding or other matter in this report, or as to any product covered by the report. Copyright ® 2013 401 ""M Page 1 of 5 ESR -2072 I Most Widely Accepted and Trusted Page 2 of 5 coating is supplied in 5 -gallon (19 L) pails and 55 -gallon (208 L) drums and has a shelf life of one year when stored in a factory -sealed container at temperatures of 50°F (10°C) or above. 3.7 Flame Seal® TB Intumescent Coating: Flame Seale TB, manufactured by Flame Seal Products Inc., is a two -component, four -to -one -by -volume, liquid - applied, water-based polymer intumescent coating. The coating is supplied in 5 -gallon (19 L) pails and 55 -gallon (208 L) drums and has a shelf life of six months when stored in a factory -sealed container at temperatures between 40°F and 90°F (4°C and 320C). 3.8 TPRZ Fireshell® BMS -TC Intumescent Coating: TPRZ Fireshell® BMS -TC intumescent coating, manufactured by TPRZ Corporation, is a one -component, water-based polymer coating. The coating is supplied in 5 -gallon (19 L) pails and 55 -gallon (208 L) drums and has a shelf life of one year when stored in factory -sealed containers at temperatures of 50°F (10°C) and above. 3.9 Paint to Protect® DC -315 Intumescent Coating: Paint to Protect® DC -315 intumescent coating, manufactured by International Fireproof Technology, Inc., is a one -component, water-based coating. The coating is supplied in 5 -gallon (19 L) pails and 55 -gallon (208 L) drums and has a shelf life of two years when stored in factory -sealed containers at temperatures between 50°F (10°C) and 80°F (270C). 4.0 INSTALLATION 4.1 General: BayseaITM Closed Cell spray foam insulation must be installed in accordance with the manufacturer's published installation instructions and this report. A copy of the manufacturer's published installation instructions must be available at all times on the jobsite during installation. 4.2 Application: The insulation is spray -applied on the jobsite using volumetric positive displacement pumps as identified in the Bayer MaterialScience application instructions. The maximum service temperature must not exceed that specified in the manufacturer's published installation instructions. The foam plastic must not be used in electrical outlet or junction boxes or in contact with water. The foam plastic must not be sprayed onto a substrate that is wet, or covered with frost or ice, loose scales, rust, oil, or grease. The insulation may be applied at a maximum thickness of 2 inches (51 mm) per pass up to the maximum total thickness as specified in Sections 3.2, 4.3 and 4.4. Additional passes may be applied after ten minutes or more of curing time. 4.3 Thermal Barrier: 4.3.1 Application with a Prescriptive Thermal Barrier: BayseaITM Closed Cell spray foam insulation must be separated from the interior of the building by an approved thermal barrier of 1/2 -inch -thick (12.7 mm) gypsum wallboard or an equivalent 15 -minute thermal barrier complying with, and installed in accordance with, IBC Section 2603.4 or IRC Section R316.4, as applicable. Thicknesses of up to 8 inches (203 mm) for wall cavities and 12 inches (305 mm) for ceiling cavities are recognized, based on room corner fire testing in accordance with NFPA 286. 4.3.2 Application without a Prescriptive Thermal Barrier: 4.3.2.1 Application with Flame Seale TB Intumescent Coating: The prescribed 15 -minute thermal barrier may be omitted when installation is in accordance with this section. The BaysealTm Closed Cell insulation and Flame Seale TB system may be used in lieu of the prescribed 15 -minute thermal barrier. The foam plastic insulation thickness must not exceed 6 inches (152 mm) in walls and ceilings, and the insulation must be covered with 18 dry mils (0.46 mm) of Flame Seale TB intumescent coating applied at a minimum rate of 1.6 gallons (6 L) per 100 square feet (9.3 mZ). The substrate must be dry, clean and free of dirt and loose debris or other substances that could interfere with the adhesion of the coating. Flame Seale TB may be applied by airless sprayer at ambient temperatures between 50°F and 115°F (10°C and 46°C) and relative humidity of less than 70 percent. 4.3.2.2 Application with TPRZ Fireshell® BMS -TC Intumescent Coating: The prescribed 15 -minute thermal barrier may be omitted when installation is in accordance with this section. The BaysealT"" Closed Cell insulation and TPRZ Fireshell® BMS -TC intumescent coating may be used in lieu of the prescribed 15 -minute thermal barrier. The foam plastic insulation thickness must not exceed 71/4 inches (184 mm) in walls and 91/4 inches (235 mm) in ceilings, and the insulation must be covered with 12 dry mils (0.30 mm) [20 wet mils (0.51 mm)], at a minimum rate of 1.24 gallons (4.7 L) per 100 square feet (9.3 mZ)]. The substrate must be dry, clean and free of dirt and loose debris or other substances that could interfere with the adhesion of the coating. TPRZ Fireshell® BMS -TC intumescent coating may be applied by airless sprayer, conventional spray, medium knap roller or brush at ambient temperatures between 62°F and 95°F (16°C and 35°C) and relative humidity of less than 70 percent. 4.3.2.3 Application with Paint to Protect® DC -315 Intumescent Coating: The prescribed 15 -minute thermal barrier may be omitted when installation is in accordance with this section. The BayseaITM Closed Cell insulation and Paint to Protect® DC -315 intumescent coating system may be used in lieu of the prescribed 15 -minute thermal barrier. The foam plastic insulation thickness must not exceed 71/4 inches (184 mm) in walls and in ceilings and the insulation must be covered with 12 dry mils [18 wet mils (0.45 mm)), at a minimum rate of 1.12 gallons (4.23 L) per 100 square feet (9.3 mz). The substrate must be dry, clean and free of dirt and loose debris or other substances that could interfere with the adhesion of the coating. Paint to Protect® DC -315 intumescent coating may be applied by airless sprayer at ambient temperatures between 50°F and 105°F (10°C and 41°C) and relative humidity of less than 80 percent. 4.3.2.4 Use as Interior Finish: The BaysealT" Closed Cell spray -applied polyurethane foam insulation and intumescent coating systems, as described in Section 4.3.2.1, 4.3.2.2 or 4.3.2.3 may be used as an interior finish in all construction types under the IBC and dwellings under the IRC. 4.4 Attics and Crawl Spaces: 4.4.1 Application with a Prescriptive Ignition Barrier: When BayseaITM Closed Cell insulation is installed within attics or crawl spaces where entry is made only for service of utilities, an ignition barrier must be installed in accordance with IBC Section 2603.4.1.6 or IRC Sections R316.5.3 and R316.5.4, as applicable. The ignition barrier must be consistent with the requirements for the type of ESR -2072 I Most Widely Accepted and Trusted Page 3 of 5 construction required by the applicable code, and must be installed in a manner so the foam plastic insulation is not exposed. The insulation as described in this section may be installed in unvented attics in accordance with 2012 IRC Section R806.5 or the 2009 IRC Section R806.4. 4.4.2 Application without a Prescriptive Ignition Barrier: 4.4.2.1 General: Where BayseaITM Closed Cell insulation is installed without a prescriptive ignition barrier as described in Section 4.4.2.2, 4.4.2.3, 4.4.3.1 or 4.4.3.2, in attics and crawl spaces, the following conditions apply: ■ Entry to the attic or crawl space is only to service utilities and no storage is permitted. ■ There are no interconnected attic or crawl space areas. ■ Air in the attic or crawl space is not circulated to other parts of the building. ■ Under -floor (crawl space) ventilation is provided when required by IBC Section 1203.3 or IRC Section R408.1, as applicable. ■ Attic ventilation is provided when required by IBC Section 1203.2 or IRC Section R806, except when air -impermeable insulation is permitted in unvented attics in accordance with 2012 Section R806.5 or 2009 IRC Section R806.4. ■ Combustion air must be provided in accordance with Section 701 of the 2009 International Mechanical Code® (IMC). 4.4.2.2 Use with BaysealTM IC intumescent Coating: BaysealTM Closed Cell insulation may be spray -applied to the underside of roof sheathing and/or rafters, and the underside of wood floors and/or floor joists in crawl spaces as described in this section. The thickness of the foam plastic applied to the underside of the wood floor or roof sheathing must not exceed 12 inches (305 mm). The thickness of the spray foam insulation applied to vertical wall surfaces in attics and crawl spaces must not exceed 8 inches (203 mm). All foam plastic surfaces must be covered with 4 dry mils (0.1 mm) of BaysealTM" IC intumescent coating, applied at a rate of 0.5 gallon (1.9 Q per 100 square feet (9.3 m2). BayseaITM IC intumescent coating may be applied by brush, roller or airless sprayer at ambient temperatures between 50°F and 115°F (10°C and 46°C) and relative humidity of less than 75 percent. Surfaces to be coated must be dry, clean, and free of dirt, loose debris and any other substances that could interfere with adhesion of the coating. BaysealT14 Closed Cell insulation, as described in this section, may be installed in unvented attics in accordance with IRC Section R806.4. 4.4.2.3 Application of BaysealTm CC X and BaysealTM' CC XP Closed Cell Insulation without Intumescent Coating: BaysealTM" CC X or BaysealT"" CC XP Closed Cell insulation may be spray -applied to the underside of roof sheathing and/or rafters and the underside of wood floors and/or floor joists in crawl spaces as described in this section. The thickness of the foam plastic applied to the underside of the wood floor or roof sheathing must not exceed 11114 inches (286 mm). The thickness of the foam plastic insulation applied to vertical surfaces in attics and crawl spaces must not exceed 71/4 inches (184 mm). BaysealTM CC X or BaysealT"' CC XP Closed Cell insulation, as described in this section, may be installed in unvented attics in accordance with 2012 IRC Section R806.5 or 2009 IRC Section R806.4. When BaysealT"' CC X or BaysealT"' CC XP Closed Cell insulation is installed in accordance with this section, the ignition barrier in accordance with IBC Section 2603.4 and IRC Section R316.5.3 may be omitted. 4.4.3 Attic Floors: 4.4.3.1 Use on Attic Floors with BaysealTM IC Intumescent Coating: BaysealTM Closed Cell insulation may be installed at a maximum thickness of 8 inches (203 mm) between and over the joists in attic floors. All foam plastic surfaces must be covered with 4 dry mils (0.1 mm) of BaysealTM" IC intumescent coating uniformly applied at a rate of 0.5 gallons (1.9 Q per100 square feet (9.3 m2). BaysealT14 IC intumescent coating may be applied by brush, roller or airless sprayer at ambient temperatures between 50°F and 115°F (10°C and 46oC) and relative humidity of less than 75 percent. Surfaces to be coated must be dry, clean, and free of dirt, loose debris and any other substances that could interfere with adhesion of the coating. The insulation must be separated from the interior of the building (beneath the attic) by an approved thermal barrier. The ignition barrier in accordance with IBC Section 2603.4 and IRC Section R316.5.3 may be omitted. 4.4.3.2 Use of BaysealTM CC X and BaysealTM CC XP Closed Cell Insulation on Attic Floors without Intumescent Coating: BaysealTM" CC X or BaysealTM CC XP Closed Cell insulation may be installed exposed at a maximum thickness of 71/4 inches (184 mm) between and over joists in attic floors without a code -prescribed ignition barrier or intumescent coating. The insulation must be separated from the interior of the building by an approved thermal barrier. The ignition barrier in accordance with IBC Section 2603.4.1.6 and IRC Section R316.5.3 may be omitted. 4.5 Water -resistive Barrier: BayseaIT"' Closed Cell spray -applied polyurethane foam insulation may be used as the water -resistive barrier prescribed in IBC Section 1404.2 and IRC Section R703.2, when installed on exterior walls as described in this section. The insulation must be spray -applied to the exterior side of the sheathing, masonry or other suitable exterior wall substrates to form a continuous layer of 1 inch (25.4 mm) minimum thickness. All construction joints and penetrations are to be completely sealed with BayseaIT"' Closed Cell insulation. Optionally, self -adhering flexible flashing materials complying with ICC -ES Acceptance Criteria for Flexible Flashing (AC148), dated February 2011, may be installed around penetrations and openings prior to application of the BayseaIT"" Closed Cell spray - applied insulation. 4.6 Exterior Walls in Types I, II, III and IV Construction: When used on walls of Type I, Il, III and IV construction, the assembly in which the BayseaIT"" Closed Cell spray - applied polyurethane insulation is used must comply with Section 2603.5 of the IBC and must be installed at a maximum thickness of 3.25 inches (82.6 mm) in accordance with the manufacturer's published installation instructions and this report. The potential heat of the BaysealTm Closed Cell spray -applied polyurethane insulation is 1838 Btu/ft2 (20.9 MJ/m2) per inch of thickness when tested in accordance with NFPA 259. Wall assemblies complying with this section must be as described in Table 2. 5.0 CONDITIONS OF USE The BaysealTM Closed Cell spray -applied foam plastic insulations described in this report comply with, or are suitable alternatives to what is specified in, those codes listed in Section 1.0 of this report, subject to the following conditions: ESR -2072 I Most Widely Accepted and Trusted Page 4 of 5 5.1 The products must be installed in accordance with the manufacturer's published installation instructions, this evaluation report and the applicable code. The instructions within this report govern if there are any conflicts between the manufacturers' published installation instructions and this report. 5.2 The insulation must be separated from the interior of the building by an approved 15 -minute thermal barrier, except when installation is as described in Sections 4.3.2 and 4.4. 5.3 The insulation must not exceed the thicknesses noted in Sections 3.2, 4.3 and 4.4 of this report. 5.4 The insulation must be protected from prolonged exposure to weather during application. 5.5 The insulation must be applied by contractors certified by Bayer Materia lScience, LLC. 5.6 When use is on buildings of Types I, ll, III and IV construction, construction must be as described in Section 4.6 and Table 2. 5.7 Use of the insulation in areas where the probability of termite infestation is "very heavy" must be in accordance with IRC Section R318.4 or IBC Section 2603.8, as applicable. 5.8 Jobsite certification and labeling of the insulation must comply with IRC Sections N1101.4 and N1101.4.1 and IECC Sections 303.1.1 and 303.1.2, as applicable. 5.9 Use of the insulations in fire -resistance -rated construction is outside the scope of this report. 5.10 BaysealTM Closed Cell spray -applied foam insulations are produced by Bayer MaterialScience, LLC, in Spring, Texas, under a quality control program with inspections by UL LLC (AA -668). 6.0 EVIDENCE SUBMITTED 6.1 Data in accordance with the ICC -ES Acceptance Criteria for Spray -applied Foam Plastic Insulation (AC377), dated June 2012, including reports of tests in accordance with Appendix X. 6.2 Reports of room corner tests in accordance with NFPA 286 and UL 1715. 6.3 Report of potential heat of foam plastics tests in accordance with NFPA 259. 6.4 Report of air leakage tests in accordance with ASTM E283. 6.5 Data in accordance with the ICC -ES Acceptance Criteria for Foam Plastic Sheathing Panels Used as Water -resistive Barriers (AC71), dated February 2003 (editorially revised March 2011). 6.6 Report of water vapor transmission testing in accordance with ASTM E96. 6.7 Report of fire propagation characteristics testing in accordance with NFPA 285. 6.8 An engineering analysis supporting the report of testing in accordance with NFPA 285. 7.0 IDENTIFICATION Components for BaysealTM Closed Cell spray -applied foam plastic insulations are identified with the manufacturer's name (Bayer Material Science, LLC), address and telephone number, the product name (BaysealTM CC, BaysealTM CC Polar, BaysealTM CC X or BaysealTM CC XP); mixing instructions; the density; the flame -spread and smoke -development indices; the evaluation report number (ESR -2072); and the name of the inspection agency (UL LLC). Intumescent coatings are identified with the manufacturer's name and address, the product name and use instructions. 8.0 OTHER CODES In addition to the codes referenced in Section 1.0, the products described in this report were evaluated for compliance with the requirements of the following codes: ■ 2006 International Building Code® (2006 IBC) ■ 2006 International Residential Code (2006 IRC) ■ 2006 International Energy Conservation Code (2006 IECC) ■ 2003 International Building Code® (2003 IBC) ■ 2003 International Residential Code (2003 IRC) ■ 2003 International Energy Conservation Code® (2003 IECC) The products comply with the above-mentioned codes as described in Sections 2.0 through 7.0 of this report, with the revisions noted below: ■ Application with a Prescriptive Thermal Barrier: See Section 4.3.1, except the approved thermal barrier must be installed in accordance with Section R314.4 of the 2006 IRC or Section R314.1.2 of the 2003 IRC, as applicable. ■ Application with a Prescriptive Ignition Barrier: See Section 4.4.1 except attics must be vented in accordance with Section 1203.2 of the 2006 and 2003 IBC or Section R806 of the 2003 IRC, and crawl space ventilation must be in accordance with IBC Section 1203.3 of the 2006 and 2003 IBC or IRC Section R408, as applicable. Additionally, an ignition barrier must be installed in accordance with Sections R314.5.3 or R314.5.4 of the 2006 IRC or Section R314.2.3 of the 2003 IRC, as applicable. ■ Application without a Prescriptive Ignition Barrier: See Section 4.3.2, except attics must be vented in accordance with Section 1203.2 of the 2006 and 2003 IBC or Section R806 of the 2003 IRC, and crawl space ventilation must be in accordance with IBC Section 1203.3 of the 2006 and 2003 IBC or IRC Section R408, as applicable. ■ Protection against Termites: See Section 5.7, except use of the insulation in areas where the probability of termite infestation is "very heavy" must be in accordance with Section R320.5 of the 2006 IRC or Section R320.4 of the 2003 IRC. ■ Jobsite Certification and Labeling: See Section 5.9, except jobsite certification and labeling must comply with Sections 102.1.1 and 102.1.1.1, as applicable, of the 2006 IECC. ESR -2072 I Most Widely Accepted and Trusted Page 5 of 5 TABLE 1—THERMAL RESISTANCE (R -VALUES)' THICKNESS (inches) R -VALUE (°F.ft2.h/Btu) 1 6.9 2 14 3 21 3.5 24 4 28 5 34 5.5 38 6 41 7 48 7.5 52 8 55 9 62 10 69 11 76 12 83 For SI: 1 inch = 25.5 mm; 1 °F.ft2.h/Btu = 0.176 110°K.m2/W. 'R -values are calculated based on tested K values at 1 and 3.5 -inch thicknesses. TABLE 2—NFPA 285 COMPLYING EXTERIOR WALL ASSEMBLIES WALL COMPONENT MATERIALS Base Wall System – 1 –Concrete wall Use either 1, 2 or 3 2 – Concrete masonry wall 3 – 1 layer 5/8 -inch -thick Type X gypsum wallboard complying with ASTM C36 or C1396 on the interior, installed over minimum 3 /8 -inch -deep, No. 20 gage, C-shaped steel studs, spaced a maximum of 24 inches on center with lateral bracing every 4 feet vertically. Gypsum wallboard must be attached with No. 6, 11/4 -inch -long self -tapping screws located 8 inches on center along the perimeter and in the field of wallboard. Gypsum wallboard joints must be taped and treated with joint compound in accordance with ASTM C840 or GA -216 Floorline Firestopping 4 pcf mineral wool (e.g., Thermafiber) in each stud cavity at each floorline, attached with Z -clips Cavity Insulation – Use either 1, 2 or 3 1 – None 2 – Fiberglass batt insulation (faced or unlaced) 3 – Bayseal closed cell or open cell insulation Exterior Sheathing – Use either 1 or 2 1 –'/z -inch -thick, exterior -type gypsum sheathing 2 – 5/8 -inch -thick, exterior -type gypsum sheathing Exterior Insulation Bayseallm closed cell SPF, up to a maximum nominal thickness of 3 inches Exterior Wall Covering – 1 – Brick - standard nominally 4 -inch -thick clay brick; brick veneer anchors – standard types Use either 1, 2 or 3 installed a maximum of 24 inches OC vertically on each stud – Maximum 2 -inch air gap between exterior insulation and brick 2 – Stucco - minimum /,-inch-thick, exterior cement plaster and lath. A secondary water - resistive barrier may be installed between the exterior insulation and the lath. The secondary water -resistive barrier must not be full -coverage asphalt or butyl- based self -adhered membranes 3 – Minimum 2 -inch -thick limestone. Any standard non -open -jointed installation technique such as ship -lap, etc., may be used For SI: 1 inch = 25.4 mm; 1 pcf = 16.018 kg/m'. Electronically Filed by Heather Clark and Authenticated at CalCERTS.com - 6/10/2014 Electronically Signed at CalCERTS.com by Anat Shmariahu (ANAV Design) 6/10/2014 PERFORMANCE CERTIFICATE: Residential Part 1 of 5 CF -1 R Project Name Asao Residence Building Type m Single Family ❑ Addition Alone ❑ Multi Family ® Existing+ Addition/Alteration Date 6/10/2014 Project Address 10540 Chace Drive Cupertino California Energy Climale Zone CA Climate Zone 04 Total Cond. Floor Area 2,755 Addition 164 # of Stories 1 FIELD INSPECTION ENERGY CHECKLIST IZI Yes ❑ No HERS Measures -- If Yes, A CF -4R must be provided per Part 2 of 5 of this form. ❑ Yes ❑ No Special Features -- If Yes, see Part 2 of 5 of this form for details. INSULATION Construction Type Area Special Cavity (ft) Features (see Part 2 of 5) Status Wall Wood Framed R-13 1,830 Altered Door Opaque Door None '20 Altered Wall Wood Framed R-13 2 % '089 Efl 1,f, Altered Floor Wood Framed w/Crawl Space R-19 1,7 0 J JU 10 1 J &W fir, ,i Altered Roo/ Wood Framed Rafter R-19 1,1 Altered Roo/ Wood Framed Rafter R-19 767, New Roo/ Wood Framed Attic R-11 553 Existing Slab Unheated Slab -on -Grade None 557 Perim = 49' Existing FENESTRATION U- Orientation Area(ft) Factor Exterior SHGC Overhang Sidefins Shades Status Front (E) 48.0 0.710 0.73 none none Bug Screen Altered „ „ Front (E) 79.2 1.280 ,v�� (J /brie!lone „ ,, p en Removed �;;,; r� Front (E) ;' 112.7 4 ? 0 ///i"411 F 0.7 i, hone ncsrx Cr41// New Left (S);; ;4 ? 2t0 O.f none ; /f Bu Screw Removed Left S / li `71D (R (' Lett (S) „ ,, % ;rii 7 8> ,,i% i A, 07'% none e % Screen moved 'iiit , f , n frae Iidr), , f , Bug Removed „- Left (S) 138.0 0.710 0.73 none none screen New Rear(W) 141.0 0.710 0.73 none „ Bug Screen Removed Rear (W) 97.2 0.770 0.70 none na Bug Screen New Rear (W) 150.8 0.710 0.73 none none Bug Screen New Right (N) 33.4 1.250 0.80 none none Bug Screen Removed HVAC SYSTEMS Qty. Heating Min. Eff Cooling Min. Eff Thermostat Status 1 Central Furnace 97% AFUE Split Air Conditioner 16.0 SEER Setback Altered CUPERTINO ,,I Building Qe HVAC DISTRIBUTIONWcat Location HeatingCooling Duct �1 0 1, 2014 R -Value Status 1st Floor Ducted Ducted di i ned 6.0 Altered Reviewed By_.✓ 447141/ WATER HEATING Qty. Type Gallons Min. Eff Distribution Status 1 Instant Gas 0 0.84 No Pipe Insulation Altered Ener Pro 5.1 by EnergySoft User Number- 1239 RunCode: 2014-06-10T13:58:42 ID: 05803 Page 1 or 10 Reg: 214-N0036415D-000000000-0000 Registration Date/Time: 2014/05/20 16:03:11 HERS Provider: CalCERTS, Inc Electronically Filed by Heather Clark and Authenticated at CalCERTS.com - 6/10/2014 Electronically Signed at CalCERTS.com by Anat Shmariahu (ANAV Design) 6/10/2014 PERFORMANCE CERTIFICATE: Residential Part 1 of 5 CF -1 R Project Name Asao Residence Building Type m Single Family ❑ Addition Alone ❑ Multi Family ® Existing+ Addition/Alteration Date 6/10/2014 Project Address 10540 Chace Drive Cupertino California Energy Climate Zone CA Climate Zone 04 Total Cond. Floor Area 2,755 Addition 164 # of Stories 1 FIELD INSPECTION ENERGY CHECKLIST El Yes ❑ No HERS Measures -- If Yes, A CF -4R must be provided per Part 2 of 5 of this form. ❑ Yes ❑ No Special Features -- If Yes, see Part 2 of 5 of this form for details. INSULATION Construction Type Area Special Cavity (ft) Features see Part 2 of 5) Status Floor Wood Framed w/o Crawl Space R-19 195 Altered Wall Wood Framed R-13 359 New Floor Wood Framed w/Crawl Space R-19 164 New FENESTRATION U- Orientation Area(fl Factor Exterior SHGC Overhang Sidefins Shades Status Right (N) 23.8 1,280 0.80 none none Bug Screen Removed Right (N) �y 93.0 0 710one;„ ngne �� y,Sreen„ New Right (N)�!, , 17.8 D i0" ri 1X.70 0 done natal �' Suger¢n . New Skylight , 8i1 , q 840 0. nrxh$None %-, New SkyligFrf 2.4 X40 0a1 none ngne a '% None,1, /��✓ AXew Skytighf9,.., „`, 114Q,,i! w aaoa ✓aonne None New Skylight 4.0 1.980 ;,, 0.83 none none None Existing Skylight 8.0 0.840 0.67 none none None New Skylight 8.0 0.840 0.67 none none None New Skylight 8.0 0.840 0.67 none none None New Skylight 7.0 0.840 0.67 none none None New HVAC SYSTEMS Qty. Heating Min. Eff Cooling Min. Eff Thermostat Status HVAC DISTRIBUTION Location Heating Duct Cooling Duct Location R -Value Status WATER HEATING Qty. Type Gallons Min. Eff Distribution Status EnergyPro 5.1 by EnergySoft User Number: 1239 RunCode: 2014-06-10T13:58.42 /D: 05803 Pa e 2 of 10 Reg: 214-N0036415D-000000000-0000 Registration Date/Time: 2014/05/20 16:03:11 HERS Provider: CalCERTS, Inc Electronically Filed by Heather Clark and Authenticated at CalCERTS.com - 6/10/2014 Electronically Signed at Ca10ERTS.com by Anat Shmariahu (ANAV Design) 6/10/2014 PERFORMANCE CERTIFICATE: Residential Part 1 of 5 CF -1 R Project Name Asao Residence Building Type Rl Single Family ❑ Addition Alone ❑ Multi Family ® Existing+ Addition/Alteration Date 6/10/2014 Project Address 10540 Chace Drive Cupertino California Energy Climate Zone CA Climate Zone 04 Total Cond. Floor Area 2,755 Addition 164 # of Stories 1 FIELD INSPECTION ENERGY CHECKLIST El Yes ❑ No HERS Measures -- If Yes, A CF -4R must be provided per Part 2 of 5 of this form. ❑ Yes ❑ No Special Features -- If Yes, see Part 2 of 5 of this form for details. INSULATION Construction Type Area Special Cavity (ftp Features (see Part 2 of 5) Status FENESTRATION U- Orientation Area(fi`) Factor Exterior SHGC Overhang Sidefins Shades Status Skylight 7.0 0.840 0.67 none none None New Skylight 7.0 0 840 f, 0.67 ,, r]o ,,,,,, bane Fuop� New �i„t Left (S) 40.0 ? D<770 1 %0:70faone n 9 "dug scr r, New "' Skylight , ,; "8,4 ' %0#0 0.6 Hone 5r5rie '.; None New i HVAC SYSTEMS Qty. Heating Min. Eff Cooling Min. Eff Thermostat Status HVAC DISTRIBUTION Location Heating Duct Cooling Duct Location R -Value Status WATER HEATING Qty. Type Gallons Min. Eff Distribution Status Energ Pro 5.1 by Energ Soft User Number.' 1239 Run Code: 2014-06-10T13:58:42 ID: 05803 Page 3 of 10 Reg: 214-N0036415D-000000000-0000 Registration Date/Time: 2014/05/20 16:03:11 HERS Provider: CalCERTS, Inc Electronically Filed by Heather Clark and Authenticated at CalCERTS.com - 6/10/2014 Electronically Signed at CalCERTS.com by Anat Shmariahu (ANAV Design) 6/10/2014 PERFORMANCE CERTIFICATE: Residential (Part 2 of 5) CF -1 R Project Name Asao Residence Building Type m Single Family ❑ Addition Alone ❑ Multi Family ® Existing+ Addition/Alteration Date 6/10/2014 SPECIAL FEATURES INSPECTION CHECKLIST The enforcement agency should pay special attention to the items specified in this checklist. These items require special written justification and documentation, and special verification to be used with the performance approach. The enforcement agency determines the adequacy of the justification, and may reject a building or design that otherwise complies based on the adequacy of the special justification and documentation submitted. ;1 AE ' �f i, %r , HE1 � REOIlMR ; UEP��, /5/ ICATIO� Items irr'tftfs`s coot € gwtjro "tell t fr hdV11", f #fid ib certifred I Et 9§ Rater: 'tbe ihspector musf receive a completed CF -4R form for each of the measures listed below for final to be given. The HVAC Systom, 1st Floor has Ducts, Plenums and the HVAC unit located totally within Conditioned space. A certified HERS rater must visually verify the installation of the HVAC and and all Ducts and Plenums. EnerqyPro 5.1 by EnergySoft User Number: 1239 Run Code: 2014-06-10713:58:42 ID: 05803 Page 4 of 10 Reg: 214-N0036415D-000000000-0000 Registration Date/Time: 2014/05/20 16:03:11 HERS Provider: CalCERTS, Inc Electronically Filed by Heather Clark and Authenticated at CalCERTS.com - 6/10/2014 Electronically Signed at CalCERTS.com by Anat Shmariahu (ANAV Design) 6/10/2014 PERFORMANCE CERTIFICATE: Residential (Part 3 of 5) CF -1 R Project Name Building Type m Single Family ❑ Addition Alone Date Asao Residence 1 ❑ Multi Family [0 Existing+ Addition/Alteration 6/10/2014 ANNUAL ENERGY USE SUMMARY Standard Proposed Margin TDV (kBtu/ft2- r Space Heating 79.12 25.72 53.40 Space Cooling 75.46 44.39 31.07 Fans 19.87 17.99 1.88 Domestic Hot Water 17.12 12.11 5.01 Pumps 0.00 0.00 0.00 Totals 191.58 100.22 91.36 Percent Better Than Standard: 47.7% BUILDING COMPLIES - HERS VERIFICATION REQUIRED Fenestration Building Front Orientation: (E) 90 deg Ext. Walls/Roof Wall Area Area Number of Dwelling Units: 1.00 (E) 965 161 Fuel Available at Site: Natural Gas (S) 723 178 Raised Floor Area: 2,149 (LM 715 248 Slab on Grade Area: 557 (N) 722 111 Average Ceiling Height: 9.5 Roof 2,537 70 Fenestration Average U -Factor: 0.72 TOTAL: 767 Average SHGC: 0.72 Fenestration/CFA Ratio: 27.9 REMARKS 04 f ' ;; r ,r f STATEMENT OF COMPLIANCE CEPE # R-08-01-1 60 This certificate of compliance fists the building features and specifications needed to comply with Title 24, Parts 1 the Administrative Regulations and Part 6 theCU 't' Efficiency Standards of the California Code of Regulations. Heather Clarke The documentation author hereby certifies that the documentation is accurate and complete. Documentation Author Company Builders' Energy Services YQ� - 6/102014 1478 Bird Ave Heather Clark Address Name City/State/ZipCitylState/Zip San Jose, CA 95125 Phone 408-202-9075 Signed Date The individual with overall design responsibility hereby certifies that the proposed building design represented in this set of construction documents is consistent with the other compliance forms and worksheets, with the specifications, and with any other calculations submitted with this permit application, and recognizes that compliance using duct design, duct sealing, verification of refrigerant charge, insulation installation quality, and building envelope sealing require installer testing and certification and field verification by an approved HERS rater. Designer or Owner (per Business & Professions Code) Company ANA Design Address 1211 Belknap Court Name Anat Shmariahu City/State/Zip Cupertino, CA 94014 Phone 408-206-5992 Signed License # Date EnergyPro 5.1 by EnemySoft User Number: 1239 Run Code: 2014-06-10T13:58:42 /D: 05803 Pae 5 of 10 Reg: 214-N0036415D-000000000-0000 Registration Date/Time: 2014/05/20 16:03:11 HERS Provider: CalCERTS, Inc Electronically Filed by Heather Clark and Authenticated at CalCERTS.com - 6/10/2014 Electronically Signed at CalCERTS.com by Anat Shmariahu (ANAV Design) 6/10/2014 CERTIFICATE OF COMPLIANCE: Residential (Part 4 of 5) CF -1 R Project Name Asao Residence Building Type m Single Family ❑ Addition Alone ❑ Multi Family m Existing+ Addition/Alteration Date 6/10/2014 OPAQUE SURFACE DETAILS Surface Type Area U- Insulation Joint Appendix Factor Cavity Exterior Frame Interior Frame Azm Tilt Status 4 Location/Comments Wall 4071 0.102 R-13 90 90 Altered 4.3.1-A3 E=4.3.1 -A1 House Door 20 0.500 None 90 90 Altered 4.5.1-A4 E=4.5.1 -A4 House Wall 454 0.356 None 90 90 Removec 4.3.1-A1 House Wall 324 0.102 R-13 180 90 Altered 4.3.1-A3 E=4.3.1 -A1 House Wall 399 0.102 R-13 270 90 Altered 4.3.1-A3 E=4.3.1 -A1 House Wall 226 0.356 None 180 90 Remove 4.3.1-A1 House Wall 517 0.102 R-13 0 90 Altered 4.3.1-A3 E=4.3.1 -A1 House Wall 24 0.356 None 0 90 Removec 4.3.1-A1 House Door 18 0.500 None 0 90 Removeo 4.5.1-A4 House Wall 165 0.102 R-13 90 90 Altered 4.3.1-A3 (E=4.3.1 -A1) House Wall 27 0.102 R-13 180 90 Altered 4.3.1-A3 (E=4.3. 1-A 1) House Wall 27 0.102 R-13 0 90 Altered 4.3.1-A3 E=4.3.1 -A1 House Floor 1,790 0.037 R-19 0 180 Altered 4.4.1-A4 E=4.4.1 -A1 House Roof 882 0.051 R-19 90 0 Altered 4.2.2-A 12 E=4.2.1 -A2 House Roof 874 0.079 R-11 90 0 Removec 4.2.1-A2 House Roof 40 0.051 R-19 9OF 18 New 4.2.2-Al2 JHouse FENESTRATION SURFACE DETAILS ID Type Area U-Factorl SHGC2 Azm Status Glazing Type Location/Comments 1 Window 24.0 0.710 Default 0.73 1 Default 90 Altered Double Metal Clear House 2 Existing 1.280 Default 0.80 Default Single Metal Clear pre -altered for above 3 Window 11.2 1.280 Default 0.80 Default 90 Removed Single Metal Clear House 4 Window 24.0 0.710 Default 0.73 Default 90 Altered Double Metal Clear House 5 Existing 1.280 Default „ A�(J, DefauR Single Metal Glear , , , , pre altered for above 6 Wirfp11 iv' 16.2 0.710 D #autt„ ; '' 0,73 , faulC, 90 New ; pu le A9etr dear . , ;"` House 7n(ow 11.2 0,710 Ceftui,, 0.73 Defa f(i„; ' 90 New% . Do0ble *('1l fear ,, ; ; House 8 tA(iftdow 12 0 -,, 9:280 'Def cN r' 0.80 Defaul( 90 R 4"', veer Single M t Clear Howse 9 /blfow 0 ,,;7�28Q„Defa1 0.80 Detaa'%,, 90Rrrao C9.SingleNl}1;tlear`;, House, 10 fi1�%lli9ow ;t2 Gk „ ;1.280 Def ;;,; 0.8,0 Deft( 90 Ri7clve,;Single A'(9IIear „ ` hip%arse,,, 11 Wiald+w ti, 0 , %:280' default f ,,,,, 0O Qefalft , ,' Sit <irlioved`; ingte Mf Clear Hus 12 'Window 18.0 0.710 Default ' `"`' 0:73 Default 180 Removed Double Metal Clear House 13 Window 17.8 1.250 Default 0.80 Default 180 Removed Single Metal Clear Door House 14 Window 24.0 0.710 Default 0.73Default 180 New Double Metal Clear House 15 Window 24.0 0. 710Default 0.73 Default 1 1801 New I Double Metal Clear House 16 Window 12.0 0.710 Default 0.73 Default 1 1801 New I Double Metal Clear House (1) U -Factor Type: 116-A = Default Table from Standards, NFRC = Labeled Value 2 SHGC Type: 116-B = Default Table from Standards, NFRC = Labeled Value EXTERIOR SHADING DETAILS ID Window Exterior Shade Type SHGC H t Wd Len Overhanq Left Fin Ri ht Fin I Hal LExt RExt Dist Len Hat Dist Len H t 1 Bug Screen 0.76 2 Bug Screen 0.76 3 Bug Screen 0.76 4 Bug Screen 0.76 5 Bug Screen 0.76 6 Bug Screen 0.76 7 Bug Screen 0.76 8 Bug Screen 0.76 9 Bug Screen 0.76 10 Bug Screen 0.76 11 Bug Screen 0.76 12 Bug Screen 0.76 13 Bug Screen 0.76 14 Bug Screen 0.76 15 Bug Screen 0.76 16 Bug Screen 0.76 Ener Pro 5.1 by EnetgySoft User Number. 1239 Run Code: 2014-06-10T13:58:42 /D: 05803 Pae 6 of 10 Reg: 214-N0036415D-000000000-0000 Registration Date/Time: 2014/05/20 16:03:11 HERS Provider: CalCERTS, Inc Electronically Filed by Heather Clark and Authenticated at CalCERTS.com - 6/10/2014 Electronically Signed at CalCERTS.com by Anat Shmariahu (ANAV Design) 6/10/2014 CERTIFICATE OF COMPLIANCE: Residential (Part 4 of 5) CF -1 R Project Name Asao Residence Building Type m Single Family ❑ Addition Alone ❑ Multi Family m Existing+ Addition/Alteration Date 611012014 OPAQUE SURFACE DETAILS Surface Type Area U- Insulation Joint Appendix Factor Cavity Exterior Frame Interior Frame Azm Tilt Status 4 Location/Comments Roof 553 0.079 R-11 270 18 Existing 4.2.1-A2 House Roof 438 0.051 R-19 270 18 New 4.2.2-A 12 House Slab 557 0.730 None 0 180 Existin 4.4.7-A1 House Roof 112 0.051 R-19 90 0 New 4.2.2-A 12 House Wall 49 0.102 R-13 90 90 Altered 4.3.1-A3 (E=4.3.1 -A1) House Wall 67 0.102 R-13 1 90 Altered 4.3.1-A3 E=4.3.1 -A1 House Wall 67 0.102 R-13 90 Altered 4.3.1 A3 E=4.3.1 -A1 House Roof 115 0.051 R-19 0 Altered 4.2.2-A 12 E=4.2.1 -A2 House Roof 150 0.051 R-19 1270 0 Altered 4.2.2-A 12 E=4.2.1 -A2 House Floor 195 0.048 R-19 180 Altered 4.4.2-A4 (E=4.4.1 -A 1) House Wall 130 0.102 R-13 90 New 4.3.1-A3 House Wall 34 0.102 R-13 90 90 New 4.3.1-A3 House Wall 127 0.102 R-13 180 90 New 4.3.1-A3 House Wall 68 0.102 R-13 270 90 New 4.3.1-A3 House Floor 164 0.037 R-19 0 180 New 4.4.1-A4 House Roof 44 0.051 R-19 270 18 1 New 4.2.2-A 12 lHouse FENESTRATION SURFACE DETAILS ID Type Area Ll -Factor' SHGC Azm Status Glazing Type Location/Comments 17 Window 18.0 0.710 Default 0.73 Default 180 New Double Metal Clear House 18 Window 25.0 0.710 Default 0.73 Default 270 Removed Double Metal Clear House 19 Window 30.0 0.710 Default 0.73 Default 270 Removed Double Metal Clear House 20 Window 32.0 0.710 Default 0.73 Default 270 Removed Double Metal Clear House 21 Window , , 54.0 0.710 Default 0,,7q, Default 2701 Removed Doubt Metal Clear House 22 Windtw% 46.6 0.770 D auJt , ,, ,0.70 l efaudt ; , 2;70, News Double Mei /'Cle�i Doge Nouse 23 W+rrroW 48.6 0 770 pefati,,,, 0.70 Defaulf;, - 270 Nem'" l7truble Me r -Clear Dcior House 24ildow 51.0 t;710.1?efa a '; 0.73 Default <, ,%" 270 New , " Dcluble Mtl;Glear `"'-`; ` House 25 l4lidiriow 87:8 „q 71Q; rJef tl 0.73 Def ij;; 270 1�ew ,,; double d, , 1Clear Nouse , 26 f✓sf1©w f 1 Q :2 Defa'1t,.,, 0.80 De f#""' 180 l rnoved,.Single; 1 i1;Clear ' House,' 27�-Mnctcaw,,8 ,,;,?;,2f1-efac(lx;' ,, tt4,,lefe,;°,, 0' F2 t Love ` gle 1Vie 4l;Clear Door, , `' ! fouse 28 Window 18.0 1,280 Default" "'' '0,80 Default' 0 Removed Single Metal 'Clear House 29 Window 15.6 1 250 Default 0.60 Default 0 Removed Single Metal Clear Door House 30 Window 5.8 1.280 Default 0.80 Default 0 Removed Single Metal Clear House 31 JWindow 1, 18,0 0.710 Default 0.73 1 Default 0 New Double Metal Clear House 32 Window I t I Default 0 New Double Metal Clear House (1) U -Factor Type: 116-A== Default Table from Standards, NFRC = Labeled Value 2 SHGC Type: 116-B = Default Table from Standards, NFRC = Labeled Value EXTERIOR SHADING DETAILS ID Exterior Shade Type Window Ove hang Left Fin Right Fin SHGC H t Wd Len H t LExt RExt Dist Len H t Dist Len H t 17 Bug Screen 0.76 18 Bug Screen 0.76 19 Bug Screen 0.76 20 Bug Screen 0.76 21 Bug Screen 0.76 22 Bug Screen 0.76 23 Bug Screen 0.76 24 Bug Screen 0.76 25 Bug Screen 0.76 26 Bug Screen 0.76 27 Bug Screen 0.76 28 Bug Screen 0.76 29 Bug Screen 0.76 30 Bug Screen 0.76 31 Bug Screen 0.76 32 Bu Screen 0.76 Ener Pro 5.1 by EnergySoft User Number: 1239 RunCode: 2014-06-10713:58:42 ID: 05803 Page 7 of 10 Reg: 214-N0036415D-000000000-0000 Registration Date/Time: 2014/05/20 16:03:11 HERS Provider: Ca10ERTS, Inc Electronically Filed by Heather Clark and Authenticated at CalCERTS.com - 6/10/2014 Electronically Signed at CalCERTS.com by Anat Shmariahu (ANAV Design) 6/10/2014 CERTIFICATE OF COMPLIANCE: Residential (Part 4 of 5) CF -1 R Project Name Asao Residence Building Type m Single Family ❑ Addition Alone ❑ Multi Family 10 Existing+ Addition/Alteration Date 6/10/2014 OPAQUE SURFACE DETAILS Surface U- Type Area Factor Insulation Joint Appendix Cavity Exterior Frame Interiorl Frame Azm Tilt Status 4 Location/Comments Roof 133 0.051 R-19 90 0 New 4.2.2-A 12 House FENESTRATION SURFACE DETAILS ID Type Area U -Factor SHGC2 Azm Status Glazing Type Location/Comments 33 Window 17.8 0.770 Default 0.70 1 Default 0 New Double Metal Clear Door House 34 Window 12.0 0.710 Default 0.73 Default 0 New Double Metal Clear House 35 Skylight 8.0 0.840 Default 0.67 Default 90 New Skylight House 36 Skylight 2.4 0.840 Default 0.67 Default 90 New Skylight House 37 Skylight , 2.4 0,840 Default 0„fi7 Default 90 New Skylight � House 38 Skyl gfi "" 4.0 1980 D fault , %'%' 0.83 Pela, ;; Electronically Filed by Heather Clark and Authenticated at CalCERTS.com - 6/10/2014 Electronically Signed at CalCERTS.com by Anat Shmariahu (ANAV Design) 6/10/2014 CERTIFICATE OF COMPLIANCE: Residential (Part 4 of 5) CF -1 R Project Name Asao Residence Building Type m Single Family ❑ Addition Alone ❑ Multi Family m Existing+ Addition/Alteration Date 6/10/2014 OPAQUE SURFACE DETAILS Surface U- Type Area Factor Insulation Joint Appendix Cavity Exterior Frame Interior Frame Azm Tilt Status 4 Location/Comments FENESTRATION SURFACE DETAILS ID Type Area U -Factor SHGC Azm Status Glazing Type Location/Comments 49 Window 13.5 0.710 Default 0.73 Default 0 New Double Metal Clear House 50 Window 13.5 0.710 Default 0.73 Default 0 New Double Metal Clear House 51 Window 52.3 0.710 Default 0.73 Default 90 New Double Metal Clear House 52 Window 33.0 0.710 Default 0.73 Default 180 New Double Metal Clear House 53 Window 40.0 0.770 Default Default 180 New Doublq, Metal Clear Poor House 54 Wicgdp' "',','J2.0 0.710 Default,, 0.73 Default-'',; 27'0 Ne1r";` Ppub16Me#�1`--dear House 55 Sify)ight 8.0 0.840 D fall ; " 0.67 Defau ' : 270 Neal,- $kk# ht House 41 (1) U -Factor Type: (2) SHGC Type: 116-A = Default Table from Standards, NFRC = Labeled Value 116-B = Default Table from Standards, NFRC = Labeled Value EXTERIOR SHADING DETAILS ID Exterior Shade Type Window Ove hang Left Fin Right Fin SHGC H t Wd Len H t LExt RExt Dist Len I H t Dist Len H t 49 Bug Screen 0.76 50 Bug Screen 0.76 51 Bug Screen 0.76 52 Bug Screen 0.76 53 Bug Screen 0.76 54 Bug Screen 0.76 55 None 1.00 EnergyPro 5.1 by EnergySoft User Number: 1239 Run Code: 2014-06-10T13:58:42 ID: 05803 Page 9 of 10 Reg: 214-N0036415D-000000000-0000 Registration Date/Time: 2014/05/20 16:03:11 HERS Provider: CalCERTS, Inc Electronically Filed by Heather Clark and Authenticated at CalCERTS.com - 6/10/2014 Electronically Signed at CalCERTS.com by Anat Shmariahu (ANAV Design) 6/10/2014 CERTIFICATE OF COMPLIANCE: Residential (Part 5 of 5) CF -1 R Project Name Asao Residence Building Type 121 Single Family ❑ Addition Alone ❑ Multi Family m Existing+ Addition/Alteration Date 6/10/2014 BUILDING ZONE INFORMATION System Name Floor Area Zone Name New Existing Altered Removed Volume Year Built 1st Floor House 2,326 22,330 1962 Office 265 2,385 1962 Addition 164 1,476 Totals 1 1641 01 2,5911 01 1 HVAC SYSTEMS System Name Ot : Heating Type Min. Eff. Cooling Type Min. Eff. Thermostat Type Status 1st Floor 1 Central Furnace 97% AFUE Split Air Conditioner 16.0 SEER Setback Altered pre -altered for above Central Furnace 75% AFUE Split Air Conditioner 8.0 SEER Setback y HVAC„ ISTRIBlO;,`" S stem Name �i���� �," "Duct", 7leaiin ' 'Cooling Duet Location R -Value Ducts Ducts' - Tested? Status 1st Floor Ducted' Ducted Conditioned 6.0 ❑ Altered pre -altered for above Ducted Ducted Attic, Ceiling Ins, vented 2.1 ❑ WATER HEATING SYSTEMS S stem Name Qty- Type Distribution Rated Input Btuh Tank Cap. al Energy Factor or RE Standby Loss or Pilot Ext. Tank Insul. R- Value Status Generic Tankless 1 Instant Gas No Pipe Insulation 185,000 0 0.84 n1a n1a Altered Default Gas Prior to 1999 1 Small Gas pre -altered for Above 28,000 50 0.53 n1a n1a MULTI -FAMILY WATER HEATING DETAILS HYDRONIC HEATING SYSTEM PIPING Control Hot Water Piping Length ft 0 0 Cz -00 a — System Name Pipe Length Pipe Diameter Insul. Thick. 7QtyHP Plenum Outside Buried EnergyPro5.1 byEnergySoft User Number: 1239 Run Code: 2014-06-10T13:58:42 ID: 05803 Pae 10 of 10 Reg: 214-N0036415D-000000000-0000 Registration Date/Time: 2014/05/20 16:03:11 HERS Provider: CalCERTS, Inc CUPER`t INO STATEMENT OF SPECIAL I , 2013 CBC COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION ALBERT SALVADOR. P.E., C.B.O., BUILDING OFFICIAL 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3226 • FAX (406) 777-3333 • building @cupertino.orq UL 0 2 2,014 Y SITE ADDRESS This "STATEMENT APN N BP# ..................................... r 1 .. 4 Date: ... .. ... Contractor ............LL- .. ..... .. .. ... .. ..................... d Address ...1„„,t.. Vii.. h��.�.....�.�:��,�............ ...... Address............ ........ .. ........ .. City/St.......P „ , c'.f0 ....—Zip.._ .....Phone....._-............ 1d j SA �• e i GLGU..... City/St.................................................Zip...................Phone........................ .. APP .. .. Applicant.. .... .................. . Date: .... . —_..,... w Inc., n inee �.„....... ........ ....... hiie Address.. .......................................... ......... .. ,.��. Address .° ...r r� t . � w ............... ......, ........ „�..dd..i,�.. Date:.l.....1....... Vitro 15 City/St ............................... ........... Zip ........................... Phone.......,............. ._.... ... City/St O 0,05 -e Zip.i""A Phone ESCRTION PROJECT DESCRIPTION - This"STATEMENT OF SPECIAL INSPECTIONS" is submitted in fulfillment of the requirements of CBC Sections '1704 and 1705. This form is structured after and used by permission from the StrUCt ifal Engineer Association of Northern California's (SEAONC) mode statement of Special Inspections Also, included with this form is the following: ❑ 'LI'ST OF SPECIAL INSPECTtON AGENCIES (page 2). A list of testing agencies and other special inspectors that will be retained to conduct the tests and inspections for this project 'SCHEDULE OF SPECIAL INSPECTION” (page 3 — 6). The Schedule of Special Inspections summarizes the Special Inspections and tests required. Special Inspectors will refer to the approved plans and specifications for detailed special inspection requirements. Any additional tests and inspections required by the approved plans and specifications shall also be performed. Special Inspections and Testing will be performed in accordance with the approved plans and specifications, this statement and CBC Sections 1704, 1705, 1708, 1707, and 1708. Interim reports will be submitted to the Building Official and the Registered Design Professional in Responsible Charge in accordance with CBC Section 1704.1.2. A Final Report of Special inspections documenting required Special Inspections, testing and correction of any discrepancies noted in the inspections shall be submitted prior to issuance of a Certificate of Use and Occupartuy (Section 1704.1.2). The Final Report will document: ��X FFJj COP'l'""", �, iq • Required special inspections. • Correction of discrepancies noted in inspections. In the approi oThe Owner recognizes his or her obligation to ensure that the construction and toimplement this program of special inspections. In partial fulfillment of these ig the Owner faegebtlMW for the P p 9 9 "^ This placial n has been develospections as ped wired iith the understandn CBC, Section ing that the Building 0#i • Review and approve the qualifications of the Special Inspectors who will perform the inspections. • Monitor special inspection activities on the job site to assure thatair„p rming their duties as called for in this Statement of Special Inspection. ig Review submitted inspection reports. Rev!evvt,,C !3y, � f • Perform inspections as required by the local building code. t have read and agree to compfy with the ter{,ns and conditions of this statement Prepared B Project Engineer ] Architect Design Professional in Charge.1 " f t r;, ........Lic#.RSignature. —— r 1 .. 4 Date: ... Oov,Ipr Na e:: C7� �. w�er'sAuthorton� r....�... ............ Signa.............................. ...� --- .. < . . ...�..�.. Agency / Insector Na ft/e idxi PP ,q 1d j SA �• e i GLGU..... rtion r , .... .................. . Date: .... Building official or designee: r Signature . .. _... .. ............... Date:.l.....1....... I .Speciatrispeclia71-orm_2012.doc rci+ised O9i06112 LIST OF SPECIAL INSPECTION AGENCIES APPROVAL OF SPECIAL INSPECTORS: Each special inspection agency, testing facility, and Special inspector shall be recognized by the Building Official prior to performing any dudes. Special Inspection agency's listed on this form must be pre -approved and listed on Cupertino's approved Special Inspector's list Special inspectors shall' carry approved identification when performing the functions of a special inspector. Identification cards shall follow the criteria set by the California Council of Testing and Inspection Agencies. No personnel changes shall be made without first obtaining the approval of the Building Official. Any unauthorized personnel changes may result in a 'Stop Work Order" and possible permit revocation. To be pre- approved by the City of Cupertino, refer to the SPECIAL INSPECTION CRITERIA handout Please allow two weeks to complete the application process. The foilowinq are the testing and special inspection agencies that will be retained to conduct tests and inspection on this proiect EXPERTISE FIRM t INSPECTOR INFORMATION 1, Special Inspection (except for geotechnicaq Finn/ % ! ........ �1 LH PC.II �....Addr...,1.........a�!l/.... .. ........ �r .. �F.................... City..�5.l/��' f.A .....d.Q.gS..� ............... ... ..,.,....................................... SI .. . ......... 1P.9 � .y.. r..� r �.7'1�.77......... �. J � Telepho►faC Fa bl..%.�C...:1.2 .... Email ....> 2. Material Testing Finn ............................................... ............ .......... Addr............................ .................. .............................. ............. City.......................................................................................................... State .......................Zip ...................... Telephone.......................................Fax............................................ Email ................ .............. ................... ........ 3. Geotechnical Inspections Finn ............ ......................... ...................... .......... Addr......................................................................................... City.......................................................................................................... State ......................Zip ...................... Telephone...................................... Fax— .............................. ........... Email ................................................ ......... 4. Other. Finn.....................................................................Addr.....................................................-----............................... City.......................................................................................................... State -........ .............. zip ...................... Telephone...................................... Fax............................................ Email ............. .................... _...... ........ ........ 'All agencies specified on this form must be pre -approved and listed on the City of Cupertino's Approved Special Inspector's List. SEISMIC REQUIREMENTS (Section 1705,3.6) Description of seismic -force -resisting system and designated seismic systems subject to special inspections as per Section 1705.3: The extent of the seismicforce-resisting system is defined in more detail in the construction documents. Description of main wind -force -resisting system and designated wind resisting components subject to special inspections in accordance with Section 1705.42: The extent of the main wind -force -resisting system and wind resisting components is defined in more detail in the construction documents. SpecialnspectionForm_2012.doc revised 09/06/12 M CUPERTINO STATEMENT OF SPECIAL INSPECTIONS, 2013 CBC COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building@cupertino.org SITE ADDRESS APN3Z y 1 3 D?T b -7 BP# Owner....... %�.....�.J�.LLQ........................................................................ Contractor....................................................................................................... Owner Nalne: Auan Address...�4. .` ?...-,r11.RZ,e D.J,................................................. Address...................,....................................................................................... Inspection Agency / Inspector Name: City/St....... cz e,ecAro—a....... zip .... 7.4P..?4..... Phone ...... -............ City/St.................................................Zip...................Phone........................ Applicant........................................................................................................ Enginee rchitect...... 5.6. A.Cq.( 1f-,D%G............................. Address........................................................................................................... . ........... Address. ..... zDs.5..L,,..cohn--Aw........... ........i"-* City/St............................................. Zip................... ........ Phone ................... .. Cit /st.....%n. t.tl &e.............. y Zip.G�,....... Phone 26.x,-•���{J PROJECT DESCRIPTION: �,, t7 m i t This "STATEMENT OF SPECIAL IN form is structured after and used by statement of Special Inspections. A ❑ "LIST OF SPECIAL INSA retained to GondV the% "SCHEDULE Inspections astt§ inspection re CJS" is submitted in fulfillment of the requirements of CBC Sections 1704 and 1705. This from the Structural Engineer Association of Northern California's (SEAONC) mode ded with this form is the following: I AGENCIES (page 2). A list of testing agencies and other special inspectors that will be inspections for this project ACTION" (page 3 – 6). The Schedule of Special Inspections summarizes the Special jgcial Inspectors will refer to the approved plans and specifications for detailed special j$ional tests and inspections required by the approved plans and specifications shall also be performe Special Inspections ani "bt pe rft rmed in accordance with the approved plans and specifications, this statement and CBC Sections 1704, 1705, 6, 7, end ?708. Interim reports will be submitted to the Building Official and the Registered Design Professional in Res ' i aw"°gin acordance with CBC Section 170 RECEIVED A Final Report ofip on documenting required Special Inspe tions, testing and correction c If any discrepancies noted in the inspections shall i 'prior,")o issuance of a Certificate of Use 3ndO4LWn1y#Sf Q* 170z. 1.2). The Final Report will document:w • Required spe in4*tii n f • Correction of crcies noted in inspections. The Owner recognizili or er obligation to ensure that the construction complies with the approved permit documents and to implement this prog%wecial inspections. In partial fulfillment of these obligations, the Owner will retain and directly pay for the Special Inspections as rt hied in CBC Section 1704.1. This plan has been de loped with the understanding that the Building Official will: • Review and approve the qualifications of the Special Inspectors who will perform the inspections. • Monitor special inspection activities on the job site to assure that the Special Inspectors are qualified and are performing their duties as called for in this Statement of Special Inspection. • Review submitted inspection reports. • Perform inspections as required by the local building code. 1 have read and agree to comply with the teW _gnd conditions of this statement Prepared By: Project A Engineer ❑ Architect)) Registered Design Professional in Charge Signature ...94U.. � / ....... .... .. .. .1............ Lic.# ..�1....51.16.........1.Date: .Cls./7:74... Owner Nalne: Auan Signature r " Date:...... ....1. ...L. .. Inspection Agency / Inspector Name: Signature.................................................................... Lic.#....................................... Date:.......................... Building Official or designee: Signature.................................................................................................................... Date:.......................... Specialnspectionrornr 2012. doe revised 09106,112 LIST OF SPECIAL INSPECTION AGENCIES APPROVAL OF SPECIAL INSPECTORS: Each special inspection agency, testing facility, and special inspector shall be recognized by the Building Official prior to performing any duties. Special Inspection agency's listed on this form must be pre -approved and listed on Cupertino's approved Special Inspector's list. Special inspectors shall carry approved identification when performing the functions of a special inspector. Identification cards shall follow the criteria set by the California Council of Testing and Inspection Agencies. No personnel changes shall be made without first obtaining the approval of the Building Official. Any unauthorized personnel changes may result in a "Stop Work Order" and possible permit revocation. To be pre- approved by the City of Cupertino, refer to the SPECIAL INSPECTION CRITERIA handout. Please allow two weeks to complete the application process. The following are the testing ands ecial inspection agencies that will be retained to conduct tests and inspection on this project EXPERTISE FIRM ! INSPECTOR INFORMATION 1. Special Inspection (except for Firm.....................................................................Addr......................................................................................... geotechnical) City ..................................................................................................... ..... State .......................Zip ...................... Telephone...................................... Fax ............................................ Email......................................................... 2. Material Testing Firm.....................................................................Addr......................................................................................... City.......................................................................................................... State .......................Zip ...................... Telephone....................................... Fax ............................................ Email......................................................... 3. Geotechnical Inspections Firm .................. ................................................... Addr......................................................................................... City.......................................................................................................... State .......................Zip ...................... Telephone...................................... Fax ............................................ Email......................................................... 4. Other: Firm.....................................................................Addr......................................................................................... City.......................................................................................................... State .......................Zip ...................... Telephone...................................... Fax ............................................ Email ......................................................... *All agencies specified on this form must be pre -approved and listed on the City of Cupertino's Approved Special Inspector's List. SEISMIC REQUIREMENTS (Section 1705.3.6) Description of seismic -force -resisting system and designated seismic systems subject to special inspections as per Section 1705.3: The extent of the seismic -force -resisting system is defined in more detail in the construction documents. WIND REQUIREMENTS Section 1705.4.1 Description of main wind -force -resisting system and designated wind resisting components subject to special inspections in accordance with Section 1705.4.2: The extent of the main wind -force -resisting system and wind resisting components is defined in more detail in the construction documents. SpecialnspectionForrn_2012.doc revised 09/06/12 SCHEDULE OF SPECIAL INSPECTION SITE APN BP# ADDRESS PROJECT DESCRIPTION: Notation Used in Table: Column headers: C Indicates continuous inspection is required. P Indicates periodic inspections are required. The notes and/or contract documents should clarify. Box entries: X Is placed in the appropriate column to denote either "C" continuous or "P" periodic inspections. — Denotes an activity that is either a one-time activity or one whose frequency is defined in some other manner. Additional detail regarding inspections and tests are provided in the project specifications or notes on the drawings. VERIFICATION AND INSPECTION C I P REFERENCED IBC REFERENCE STANDARD INSPECTION OF FABRICATORS 1. ❑ Inspect fabricator's fabrication and quality control — 1704.3 procedures. INSPECTION OF STEEL 1. Material verification of high-strength bolts, nuts and washers. ❑ Identification marking to conform to ASTM stds AISC 360, specified in the approved construction documents. — X Section A3.3 and applicable ASTM material standards ❑ Inspect fabricators fabrication and quality control — X — — procedures. 2. Inspection of high-strength bolting: ❑ Snug -tight joints. — X ❑ Pretensioned and slip -critical joints using turn -of -nut with matchmarking, twist -off bolt or direct tension — X AISC 360, indicator methods of installation. Section M2.5 1704.3.3 ❑ Pretensioned and slip -critical joints using tum -of -nut Without matchmarking or calibrated wrench methods X of installation. 3. Material verification of structural steel and cold -formed steel deck. ❑ For structural steel, identification markings to conform — X AISC 360, to AISC 360. Section M2.5 ❑ For other steel, identification markings to conform to Applicable ASTM ASTM standards specified in the approved -- X material standards construction documents. ❑ Manufacturer's certified test reports. — X Specia/nspectionForm_2012.doc revised 09/06/12 VERIFICATION AND INSPECTION C -F- p --F REFERENCED STANDARD IBC REFERENCE 4. Material verification of weld filler materials: ❑ Identification marking to conform to AWS specification in the approved construction documents. — X AISC 360, Section A3.5 and applicable AWS A5 documents — ❑ Manufacturer's certificate of compliance required. — X — — 5. Inspection of welding: a. Structural steel and cold -formed steel deck: ❑ Complete and partial joint penetration groove welds. X — AWS D1.1 1704.3.1 ❑ Multipass fillet welds. X — E) Single -pass fillet welds > 5/16" X -- ❑ Plug and slot welds. X — ❑ Single -pass fillet welds <= 5/16" — X ❑ Floor and roof deck welds. — X AWS 01.3 b. Reinforcing steel: ❑ Verification of weldability of reinforcing steel other than ASTM A 706. — X AWS D1.4 ACI 318: Section 3.5.2 — ❑ Reinforcing steel resisting flexural and axial forces in intermediate and special moment frames, and boundary elements of special structural walls of concrete and shear reinforcement. X— ❑ Shear reinforcement. X — ❑ Other reinforcing steel. — X 6. Inspection of steel frame joints details for compliance: ❑ Details such as bracing and stiffening. — X — 1704.3.2 ❑ Member locations. — X ❑ Application of joint details at each connection. — X VERIFICATION AND INSPECTION C p REFERENCED STANDARD IBC REFERENCE INSPECTION OF WELDING 1. ❑ Welded studs when used for structural diaphragms. — X -- 1704.3 2. ❑ Welding of cold -formed steel framing members. — X 3. ❑ Welding of stairs and railing systems. — X SpecialnspeclionForm_2012.doc revised 09/06/12 VERIFICATION AND INSPECTION C P REFERENCED IBC STANDARD REFERENCE INSPECTION OF CONCRETE 1. ❑ Inspection of reinforcing steel, including prestressing _ X ACI 318: 3.5, 7.1-7.7 1913.4 tendons and placement. 2. ❑ Inspection of reinforcing steel welding in accordance AWS D1.4 ACI 318: with Table 1704.3 Item 5b. _ 3.5.2 3. ❑ Inspection of bolts to be installed in concrete prior to and during placement of concrete where allowable X ACI 318:8.1.3, 1911.5, 1912.1 loads have been increased or where strength design 21.2.8 is used. 4. X Inspection of anchors installed in hardened concrete. --- X ACI 318: 1912.1 5. ❑ Verifying use of required design mix. 1904.2.2,1913.2, -_- X ACI 318: 1913.3 6. ❑ At time fresh concrete is sampled to fabricate ASTM C 172 specimens for strength tests, perform slump and air X -- ASTM C 31 1913.10 content tests and determine the temperature of the concrete. ACI 318: 5.6, 5.8 7. ❑ Inspection of concrete and shotcrete placement for X --- ACI 318: 5.9, 5.10 1913.6, 1913.7, proper application techniques. 1913.8 8. ❑ Inspection for maintenance of specified curing -_- X ACI 318: 5.11-5.13 1913.9 temperature and techniques. 9. Inspection of prestressed concrete: ❑ Application of prestressing forces. X --- ACI 318: 18.20 ❑ Grouting of bonded prestressing tendons in the X --- ACI 318: 18.18.4 -' seismic force -resisting system. 10. ❑ Erection of precast concrete members. --- X ACI 318: Ch. 16 -- 11. ❑ Verification of in-situ concrete strength, prior to stressing of tendons in posttensioned concrete and _ X ACI 318: 6.2 --- prior to removal of shores and forms from beams and structural slabs. 12. ❑ Inspect formwork for shape, location, and dimensions _-_ X ACI 318: 6.6.1 of the concrete member being formed. 13. ❑ Bolts Installed in Existing Masonry or Concrete ❑ Direct tension testing of existing anchors. --- X See ICC ES Reports form special inspection requirements for proprietary products ❑ Direct tension testing of new bolts. -- X ❑ Torque testing of new bolts. __ X ❑ Prequalification test for bolts and other types of X anchors. 14. ❑ Other: Speciahispeclio"Form_2012.doc revised 09106112 SpecialnspectionForm 2012.doc revised 09/06/12 REFERENCE FOR CRITERIA VERIFICATION AND INSPECTION C P IBC TMS 402/ACI TMS 402/ACI SECTION 530/ASCE 5 530/ASCE 6 INSPECTION OF LEVEL 1 MASONRY 1. ❑ Compliance with required inspection provisions of the construction documents and the approved — X — — Art. 1.5 submittals shall be verified. 2. ❑ Verification of f ,and franc prior to construction — X — — Art. 1.413 except where specifically exempted by this code. 3. ❑ Verification of slump flow and VSI as delivered to . X — -- — Art. 1.5B.1.b.3 the site for self consolidating grout. 4. As masonry construction begins, the following shall be verified to ensure compliance: ❑ Proportions of site -prepared mortar. — X -- — Art. 2.6A ❑ Construction of mortar joints. — X — — Art.3.313 ❑ Location of reinforcement, connectors, — X — -- Art. 3.4, 3.6A prestressing tendons, and anchorages. ❑ Prestressing technique. — X -- — Art. 3.613 ❑ Grade and size of prestressing tendons and — X — — Art. 2.413, 2.4H anchorages. 5. During construction the inspection program shall verify: ❑ Size and location of structural elements. -- X — — Art. 3.3F ❑ Type, size, and location of anchors, including Sec. 1.2.2(e), other details of anchorage of masonry to — x — 1.16.1 — structural members, frames or other construction. ❑ Specified size, grade, and type of reinforcement, anchor bolts, prestressing tendons and -- x -- Sec. 1.15 Art. 2.4, 3.4 anchorages. ❑ Welding of reinforcing bars. x — — — ❑ Preparation, construction and protection of masonry during cold weather (temperature below — x Sec. 2104.3, Art. 1.8C, 1.8D 40 degrees F) or hot weather (temperature above 2104.4 90 degrees F). ❑ Application and measurement of prestressing x — — — Art. 3.66 force. 6. Prior to grouting the following shall be verified to ensure compliance: ❑ Grout space is clean. — x -- — Art. 3.2D ❑ Placement of reinforcement and connectors and x — Sec. 1.3 Art. 3.4 prestressing tendons and anchorages. ❑ Proportions of site -prepared grout and — x -- — Art. 2.613 prestressing grout for bonded tendons. ❑ Construction of mortar joints. -- x — — Art. 3.313 7. Grout placement: ❑ Grout placement shall be verified ensure x — — — Art. 3.5 compliance. ❑ Observe grouting of prestressing bonded x — — — Art 3.6C tendons. SpecialnspectionForm 2012.doc revised 09/06/12 SpecialnspectionForm_2012.doc revised 09/06/12 REFERENCE FOR CRITERIA VERIFICATION AND INSPECTION C P IBC TMS 402/ACI TMS 402/ACI SECTION 530/ASCE 5 530/ASCE 6 8. ❑ Preparation of any required grout specimens, Sec. mortar specimens, and/or prisms shall be — X 2105.2.2, — Art. 1.4 observed. 2105.3 INSPECTION OF LEVEL 2 MASONRY 1. ❑ Compliance with required inspection provisions of the construction documents and the approved — X — — Art. 1.5 submittals. 2. ❑ Verification of fm and fw+c prior to construction and for every 5,000 square feet during — X — — Art. 1.413 construction. 3. ❑ Verification of proportions of materials in premixed or preblended mortar and grout as — X — — Art. 1.513 delivered to the site. 4. ❑ Verification of slump flow and VSI as delivered to X — — -- Art. 1.513.1.b.3 the site for self consolidating rout. 5. The following shall be verified to ensure compliance: ❑ Proportions of site -prepared mortar, grout, and — X -- — Art. 2.6A prestressing grout for bonded tendons. ❑ Placement of masonry units and construction of — X — — Art. 3.313 mortar joints. ❑ Placement of reinforcement, connectors and — X — Sec. 1.15 Art. 3.4, 3.6A prestressing tendons and anchorages. ❑ Grout space prior to grouting. X — — — Art. 3.2D ❑ Placement of grout. X — — — Art. 3.5 ❑ Placement of prestressing grout. X — — — Art. 3.6C ❑ Size and location of structural elements. — X -- — Art. 3.3F ❑ Type, size, and location of anchors, including other details of anchorage of masonry to X -- — Sec.1.2.2(e) — structural members, frames and other construction. ❑ Specked size, grade, and type of reinforcement, anchor bolts, prestressing tendons and — X — Sec. 1.15 Art. 2.4, 3.4 anchorages. ❑ Welding of reinforcing bars. X — — Sec. 2.1.9.7.2, -- 3.3.3.4 (b) ❑ Preparation, construction, and protection of masonry during cold weather (temperature below _ X Sec. 2104.3, — Art. 1.8C, 1.8D 40 degrees F) or hot weather (temperature above 2104.4 90 degrees F). ❑ Application and measurement of prestressing X — — — Art. 3.613 force. 6. ❑ Preparation of any required grout specimens, Sec. mortar specimens, and/or prisms shall be X — 2105.2.2, — Art. 1.4 observed. 2105.3 SpecialnspectionForm_2012.doc revised 09/06/12 VERIFICATION AND INSPECTION C p REFERENCED IBC STANDARD REFERENCE INSPECTION OF WOOD 1. ❑ Inspect prefabricated wood structural elements and assemblies in accordance with Section 1704.2. — _ — 1704.6 2. ❑ Inspect site built assemblies. — — 3. Inspect high-load diaphragms: ❑ Verify grade and thickness of sheathing. — — ❑ Verify nominal size of framing members at adjoining panel edges. '- _ — 1704.6.1 ❑ Verify nail or staple diameter and length, — — ❑ Verify number of fastener lines, — -- ❑ Verify spacing between fasteners in each line and at edge margins. - 4. ❑ Metal-plate-connected wood trusses spanning 60 feet or greater: Verify temporary installation restraint/bracing and the permanent individual truss — X — 1704.6.2 member bracing are installed in accordance with the approved truss submittal package. REQUIRED VERIFICATION AND INSPECTION OF SOIL 1. ❑ Verify materials below footings are adequate to _ X achieve the desired bearing capacity. 2. ❑ Verify excavations are extended to proper depth and _ X have reached proper material. 3. ❑ Perform classification and testing of compacted fill _ X materials. -- Table 1704.7 4. ❑ Verify use of proper materials, densities and lift thicknesses during placement and compaction of X — compacted fill. 5. ❑ Prior to placement of compacted fill, observe subgrade — X and verify that site has been prepared properly. REQUIRED VERIFICATION AND INSPECTION OF DEEP DRIVEN FOUNDATION ELEMENTS 1. ❑ Verify element materials, sizes and lengths comply X — with the requirements. 2. ❑ Determine capacities of test elements and conduct X — additional load tests, as required. 3. ❑ Observe driving operations and maintain complete X -_ and accurate records for each element. 4. ❑ Verify locations of piles and their plumbness, confirm type and size of hammer, record number of blows per — Table 1704.8 foot of penetration, determine required penetrations to X — achieve design capacity, record tip and butt elevations and document any damage to foundation element. 5. ❑ For steel elements, perform additional inspections in accordance with Section 1704.3. — 6. ❑ For concrete elements and concrete filled elements, perform additional inspections in accordance with -- -- Section 1704.4. SpecialnspectionForm_2012.doc revised 09106112 VERIFICATION AND INSPECTION C P REFERENCED IBC STANDARD REFERENCE 7. ❑ For specialty piles, perform additional inspections as determined by the registered design professional in — -- — Table 1704.8 responsible charge. REQUIRED VERIFICATION AND INSPECTION OF CAST -IN-PLACE DEEP FOUNDATION ELEMENTS 1 ❑ Observe drilling operations and maintain complete and X — accurate records for each element. 2. ❑ Verity placement locations and plumbness, confirm element diameters, bell diameters (if applicable), lengths, embedment into bedrock (if applicable), and X — -- Table 1704.9 adequate end -bearing strata capacity. Record concrete or grout volumes. 3. ❑ For concrete elements, perform additional inspections in accordance with Section 1704.4. HELICAL PILE FOUNDATIONS 1. ❑ Record installation equipment used, pile dimensions, X --- — 1704.10 tip elevations, final depth, final installation torque. SPRAYED FIRE-RESISTANT MATERIALS Physical and visual tests 1. Condition of substrates. ❑ Inspect surface for accordance with the approved fire - resistance design and the approved manufacturer's — — written instructions. ❑ Verify minimum ambient temperature before and after — X application. — 1704.12.1 ❑ Verify ventilation of area during and after application. — X 2. ❑ Measure average thickness per ASTM E605 and — '– Section 1704.12.4. 3. ❑ Verify density of material for conformance with the approved fire-resistant design and ASTM E605. (Ref. -- — Section 1704.12.5) 4. ❑ Test cohesive/adhesive bond strength per Section 1704.12.6. _ — 5. ❑ Condition of finished application. MISCELLANEOUS 1. Mastic and Intumescent Fire -Resistant Coating. — --- -- 1704.13 2. Exterior Insulation and Finish Systems (EIFS). Water - resistive barrier coating when installed over a sheathing — — — 1704.14 substrate. 3. Special Cases — -- — 1704.15 4. Smoke Control System — — — 1704.16 5. Seismic Resistance ❑ Suspended ceiling systems and their anchorage. — — — 1705.3 [4.3] SpecialnspeclionForm_2012.doc revised 09/06/12 VERIFICATION AND INSPECTIONC P REFERENCED IBC STANDARD IREFERENCE 6. Wind Resistance ❑ Roof cladding and roof framing connections. — -- -- ❑ Wall connections to roof and floor diaphragms and framing. — -- ❑ Roof and floor diaphragm systems, including collectors, drag struts and boundary elements. — — -- ❑ Vertical wind -force -resisting systems, including braced frames, moment frames, and shear walls. — _ ❑ Wind -force -resisting system connections to the foundation. — — ❑ Fabrication and installation of systems or components required to meet the impact resistance requirements — -- of Section 1609.1.2. SPECIAL INSPECTION FOR WIND REQUIREMENTS 1. Structural Wood ❑ Inspect field gluing operations of elements of the main X — wind -force -resisting system. — 1706.2 ❑ Inspect nailing, bolting, anchoring, and other fastening of components within the main windforce-resisting – X system, including wood shear walls, wood diaphragms, drag struts, braces and hold-downs. 2. Cold -Formed Steel Framing ❑ Welding of elements of the main wind -force -resisting — X system. ❑ Inspection of screw attachments, bolting, anchoring, and other fastening of components within the main — 1706.3 wind -force -resisting system including shear walls, — X braces, diaphragms, collectors (drag struts) and hold- downs. 3. Wind -resisting components ❑ Roof cladding. — X -- 1706.4 ❑ Wall cladding. — X SPECIAL INSPECTIONS FOR SEISMIC RESISTANCE 1. ❑ Special inspection for welding in accordance with theX 1707.2 quality assurance plan requirements of AISC 341. 2. Structural Wood ❑ Inspect field gluing operations of elements of the X — seismic -force -resisting system. ❑ Inspect nailing, bolting, anchoring, and other fastening of components within the seismic -force -resisting 1707.3 system, including wood shear walls, wood -- X diaphragms, drag struts, braces, shear panels and hold-downs. 3. Cold -Formed steel light -frame construction ❑ Welding of elements of the seismic -force -resisting — X 1707.4 system. SpecialnspeclionForm_2012.doc revised 09106112 ❑ Inspection of screw attachments, bolting, anchoring, and other fastening of components within the seismic- — X force -resisting system including shear walls, braces, diaphragms, collectors (drag struts) and hold-downs. 4. Storage racks and access floors ❑ Anchorage of storage racks 8 feet or greater in height X 1707.5 and access floors. 5. Architectural components ❑ Inspect erection and fastening of exterior cladding weighing more than 5 psf and higher than 30 feet — X above grade or walking surface. ❑ Inspect erection and fastening of veneer weighing more than 5 psf.and higher than 30 feet above grade — X or walking surface. — 1707.6 ❑ Inspect erection and fastening of all exterior non- bearing walls higher than 30 feet above grade or — X walking surface. ❑ Inspect erection and fastening of all interior non- bearing walls weighing more than 15 psf and higher — X than 30 feet above grade or walking surface. 6. Mechanical and Electrical Components ❑ Inspect anchorage of electrical equipment for -- X emergency or stand-by power systems. ❑ Inspect anchorage of non -emergency electrical — X equipment. ❑ Inspect installation of piping systems and associated mechanical units carrying flammable, combustible, or — X — 1707.7 highly toxic contents. ❑ Inspect installation of HVAC ductwork that contains -- X hazardous materials. ❑ Inspect installation of vibration isolation systems — X where required by Section 1707.7. 7. ❑ Verify that the equipment label and anchorage or mounting conforms to the certificate of compliance — 1707.8 when mechanical and electrical equipment must be seismically qualified. B. ❑ Seismic isolation system: Inspection of isolation — X — 1707.9 system per ASCE 7 – Section 17.2.4.8 9. ❑ Obtain mill certificates for reinforcing steel, verify compliance with approved construction documents, — — — 1708.2 and verify steel supplied corresponds to certificate. 10. ❑ Structural Steel: Invoke the QAP Quality Assurance — — — 1708.3 requirements in AISC 341. 11. ❑ Obtain certificate that equipment has been seismically — — 1708.4 qualified. 12. ❑ Obtain system tests as required by ASCE 7 Section — — — 1708.5 17.8. SpecialnspectionForm_2012.doc revised 09/06/12 CALGREEN RESIDENTIAL CHECKLIST — MANDATORY ITEMS COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION CUPERTINO ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building a().cupertino.orq PURPOSE: The 2013 CalGreen Code applies to all newly constructed hotels, motels, lodging houses, dwellings, JUL201 BY dormitories, condominiums, shelters, congregate residences, emoyee housing, factory -built housing and W' aw other types of swellings with sleeping accommodations and new, �Ge;" buildings I�h uch uses. Existing site and landscaping improvements that are not rw e isturbed �r"I t a e requirements of CALGreen. IR g pat enf .���Jj ij d Project Name: Project Address: Project Description: Instructions: 2 3 Asao Residence rODE COMPLIANCE 10540 Chace Drive Cupertino, CA Residential Addition 0h, FFIC'L V�h . yl The Owner or the Owners agent shall employ a licensed professional'' experien'bed'with the California Green Building Standards Codes to verify and assure that all required work described herein is properly planned and implemented in the project. The licensed professional, in collaboration with the owner and the design professional shall initial Column 2 of this checklist, sign and date Section 1 - Design Verification at the end of this checklist and have the checklist printed on the approved plans for the project. Prior to final inspection by the Building Department, the licensed professional shall complete Column 3 and sign and date Section 2 - Implementation Verification at the end of this checklist and submit the completed form to the Building Inspector. Column 2 Column 3 MANDATORY FEATURE OR MEASURE Project Verification Reauirements 4.106.2 Storm water drainage and retention during construction. A plan is developed and implemented to manage storm water drainage during ❑X ❑ construction. 4.106.3 Grading and paving. The site shall be planned and developed to keep surface water away from buildings. Construction plans shall indicate how ® ❑ site grading or a drainage system will manage all surface water flows. Page I of 5 CalGreen_2014.doc revised 01115114 4.201.1 Low-rise residential buildings shall meet or exceed the minimum standard design required by the California Energy Standards. 4.303.1 Water conserving plumbing fixtures and fittings. Plumbing fixtures (water closets and urinals) and fittings (faucets and showerheads) shall comply with the following: ❑ 4.303.1.3.2 Water Closets. The effective flush volume of all water closets shall not exceed 1.28 gallons per flush. Tank -type water closets shall be certified to the performance criteria of the U.S. EPA WaterSense Specifications for Tank -type Toilets. ❑ 4.303.1.3.2 Urinals. The effective flush volume of urinals shall not exceed 0.5 gallons per flush. ❑ 4.303.1.3.1 Single Showerheads. Showerheads shall have a maximum flow rate of not more than 2.0 gallons per minute at 80 psi. Showerheads shall be certified to the performance criteria of the U.S. EPA WaterSense Specification for showerheads. ❑ 4.303.1.3.2 Multiple Showerheads serving one shower. When a shower is served by more than one showerhead, the combined flow rate of all showerheads and/or other shower outlets controlled by a single valve shall not exceed 2.0 gallons per minute at 80 psi, or the shower shall be designed to allow only one shower outlet to be in operation at a time. ❑ 4.303.1.4.1 Residential lavatory faucets. The maximum flow rate of residential lavatory faucets shall not exceed 1.5 gallons per minute at 60 psi. The minimum flow rate of residential lavatory faucets shall not be less than 0.8 gallons per minute at 20 psi. ❑ 4.303.1.3.2 Lavatory faucets in common and public use areas. The maximum flow rate of lavatory faucets installed in common and public use areas (outside of dwellings or sleeping units) in residential buildings shall not exceed 0.5 gallons per minute at 60 psi. ❑ 4.303.1.4.3 Metering faucets. Metering faucets when installed in residential buildings shall not deliver more than 0.25 gallons per cycle. ❑ 4.303.1.4.4 Kitchen Faucets. The maximum flow rate of kitchen faucets shall not exceed 1.8 gallons per minute at 60 psi. Kitchen faucets may temporarily increase the flow above the maximum rate, but not to exceed 2.2 gallons per minute at 60 psi, and must default to a maximum flow rate of 1.8 gallons per minute at 60 psi. 4.303.2 Standards for plumbing fixtures and fittings. Plumbing fixtures and fittings shall be installed in accordance with the California Plumbing Code, and shall meet the applicable standards referenced in Table 1401.1 of the California Plumbing Code. Page 2 of 5 CalGreen 2014.doc revised 01115114 Page 3 of 5 CalGreen_2014.doc revised 01/15/14 4.304.1 Irrigation controllers. Automatic irrigation systems installed at the time of final inspection shall be weather -based. ❑ 4.304.1.1 Controllers shall be weather- or soil moisture -based controllers that automatically adjust irrigation in response to changes in plants' needs as weather conditions change. ❑ 4.304.1.2 Weather -based controllers without integral rain sensors or communication systems that account for local rainfall shall have a separate wired or wireless rain sensor which connects or communicated with the controller(s). Soil moisture -based controllers are not required to have rain sensor input. /r ,r 4.406.1 Rodent proofing. Annular spaces around pipes, electric cables, conduits, or other openings in plates at exterior walls shall be protected against the passage of rodents by closing such openings with cement mortar, concrete masonry or similar method acceptable to the enforcing agency. VON // � 4.408.2 Construction waste management plan. Where a local jurisdiction does not have a construction and demolition waste management ordinance, a El construction waste management plan shall be submitted for approval to the enforcing agency. 4.410.1 Operation and maintenance manual. At the time of final inspection, an operation and maintenance manual shall be provided to the building ® ❑ occupant or owner. 4.503.1 General. Install only a direct -vent sealed -combustion gas or sealed wood -burning fireplace, or a sealed woodstove. 4.504.1 Covering of duct openings and protection of mechanical equipment during construction. Duct openings and other related air ❑X distribution component openings shall be covered during construction. 4.504.2.1 Adhesives, sealants and caulks. Adhesives, sealants and caulks shall be compliant with VOC and other toxic compound limits. 4.504.2.2 Paints and coatings. Paints, stains and other coatings shall be compliant with VOC limits. 4.504.2.3 Aerosol paints and coatings. Aerosol paints and other coatings shall be compliant with product weighted MIR Limits for ROC and other toxic ❑X compounds. Page 3 of 5 CalGreen_2014.doc revised 01/15/14 4.504.2.4 Verification. Documentation shall be provided to verify that ❑ ❑ compliant VOC limit finish materials have been used. 4.504.3 Carpet Systems. Carpet and carpet systems shall be compliant with ❑ ❑ VOC limits. 4.504.4 Resilient flooring systems. Eighty (80) percent of floor area receiving resilient flooring shall comply with the VOC-emission limits defined in the Collaborative for High Performance Schools (CHPS) Low-emitting ❑X ❑ Materials List or be certified under the Resilient Floor Covering Institute (RCFI) FloorScore program. 4.504.5 Composite wood products. Particleboard, medium density fiberboard (MDF), and hardwood plywood used in interior finish systems shall ❑X ❑ comply with low formaldehyde emission standards. 4.505.2 Concrete slab foundation. Required vapor retarders and capillary El are also required to comply with CalGreen Section 4.505.2.1. 4.505.3 Moisture content of building materials. Moisture content of building ❑ El used in wall and floor framing is checked before enclosure. �?GI/,,i/i f/ t 1� > 4.506.1 Bathroom exhaust fans. Exhaust fans which terminate outside the ❑ ❑ building are provided in every bathroom. 4.507.2. Duct systems are sized and designed and equipment is selected using the following methods: 1. Establish heat loss and heat gain values according to ACCA Manual J or equivalent. ❑ ❑ 2. Size duct systems according to ACCA 29-D (Manual D) or equivalent. 3. Select heating and cooling equipment according to ACCA 36-5 (Manual S) or equivalent. •"', �- 702.1 Installer training. HVAC system installers are trained and certified in ❑ El proper installation of HVAC systems. 702.2 Special inspection. The Licensed Professional responsible to verify CALGreen compliance is qualified and able to demonstrate competence in the ❑X ❑ discipline they inspect and verify. 703.1 Documentation. Verification of compliance with CALGreen may include construction documents, plans, specifications, builder or installer certification, inspection reports, or other methods acceptable to the enforcing ❑ El which show substantial conformance. Implementation verification shall be submitted to the Building Department after implementation of all required measures and prior to final inspection approval. Page 4 of 5 CalGreen 2014.doc revised 01/15/14 0, , CALGREEN SIGNATURE DECLARATIONS Project Name: Asao Residence Project address: 10540 Chace Drive Cupertino, CA Project Description: Residential Addition SECTION 1 — DESIGN VERIFICATION Complete all lines of Section 1 —'Design Verification" and submit the completed checklist (Columns 1 and 2) with the plans and building permit application to the Building Department. The owner and design professional responsible for compliance with CalGreen Standards have revised the plans and certify that the items checked above are hereby incorporated into the project plans and will be implemented into the project in accordance with the requirements set forth in the 2013 California Green Building Standards Code as adopted by the City of Cupertino. Owner's Signature Date Owner's Name (Please Print) Design Professional's Signature Date Design Professional's Name (Please Print) Signature of License Professional responsible for CalGreen compliance Date Name of License Professional responsible for CalGreen compliance (Please Print) Phone Email Address for License Professional responsible for CalGreen compliance SECTION 2 — IMPLEMENTATION VERIFICATION Complete, sign and submit the competed checklist, including column 3, together with all original signatures on Section 2 to the Building Department prior to Building Department final inspection. I have inspected the work and have received sufficient documentation to verify and certify that the project identified above was constructed in accordance with this Green Building Checklist and in accordance with the requirements of the 2013 California Green Building Standards Code as adopted by the City of Cupertino. Signature of License Professional responsible for CalGreen compliance Date Name of License Professional responsible for CalGreen compliance (Please Print) Phone Email Address for License Professional responsible for CalGreen compliance Page 5 of 5 CalGreen_2014.doc revised 01115114 e Project Name: e 6 Project Address: Project Description: CALGREEN SIGNATURE DECLARATIONS Asao Residence 10540 Chase Drive Cupertino, CA Home Addition SECTION 1 — DESIGN VERIFICATION Complete all lines of Section 1 —"Design Verification" and submit the completed checklist (Columns 1 and 2) with the plans and building permit application to the Building Department. The owner and design professional responsible for compliance with CalGreen Standards have revised the plans and certify that the items checked above are hereby incorporated into the project plans and will be implemented into the project in accordance with the requirements set forth in the 2010 California Green Building Standards Code as adopted by the City of Cupertino. Owners Signature Name (Please Print) Signature N Design Professional's Name (Please Print) of LicenseRrofessional responsible for CalGreen compliance Name of LiceAse Profes%ional responsible for CalGreen compliance (Please Print) Darrel@builders-energy.net Email Address for License Professional responsible for CalGreen compliance SECTION 2 — IMPLEMENTATION VERIFICATION Date T Date 05/20/2014 Date 408-718-1908 Phone Complete, sign and submit the competed checklist, including column 3, together with all original signatures on Section 2 to the Building Department prior to Building Department final inspection. I have inspected the work and have received sufficient documentation to verify and certify that the project identified above was constructed in accordance with this Green Building Checklist and in accordance with the requirements of the 2010 California Green Building Standards Code as adopted by the City of Cupertino. Signature of License Professional responsible for CalGreen compliance Date Name of License Professional responsible for CalGreen compliance (Please Print) Phone Address for License Professional responsible for CalGreen compliance Page 5 of 5 CalGreen_2010.doc revised 08/27/11 CUPERTINO PURPOSE: CALGREEN RESIDENTIAL CHECKLIST MANDAT °Cw. ITEMS COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION JUL 0 2 2014 ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255. (408) 777-3228 • FAX (408) 777-3333 • building(a�cupertino.org The 2013 CalGreen Code applies to all newly constructed hotels, motels, lodging houses, dwellings, dormitories, condominiums, shelters, congregate residences, employee housing, factory -built housing and other types of swellings with sleeping accommodations and new accessory buildings associated with such uses. Existing site and landscaping improvements that are not otherwise disturbed are not subject to the requirements of CALGreen. Instructions: The Owner or the Owner's agent shall employ a licensed professional experienced with the California Green Building Standards Codes to verify and assure that all required work described herein is properly planned and implemented in the project. The licensed professional, in collaboration with the owner and the design professional shall initial Column 2 of this checklist, sign and date Section 1 - Design Verification at the end of this checklist and have the checklist printed on the approved plans for the project. Prior to final inspection by the Builds L 1 s ment, the I FtR nal shall complete C olumn 3 and sign and date Section 2 - Imps a n Verificftomr?A b@pwmWr#iis checklist and submit the completed form to the Building Insp cu PF-V1l VJE'D F(.)P (.,'O[)E (.+ MIP iA CE MANDATORY FEATURE OR MEASURE 4.106.2 Storm water drainage and retention during construction. A plan is developed and implemented tc manage storm water drainage during construction. :olumn 2 Column 3 Project Verification Iuirements 4.106.3 Grading and paving. The site shall be planned and developed to keep surface water away from buildings. Construction plans shall indicate how ® �J site grading or a drainage system will manage all surface water flows. Page 1 of 5 CalGreen_2014.doc revised 01/15114 4.201.1 Low-rise residential buildings shall meet or exceed the minimum standard design required by the California Energy Standards. 4.303.1 Water conserving plumbing fixtures and fittings. Plumbing fixtures (water closets and urinals) and fittings (faucets and showerheads) shall comply with the following: ❑ 4.303.1.3.2 Water Closets. The effective flush volume of all water closets shall not exceed 1.28 gallons per flush. Tank -type water closets shall be certified to the performance criteria of the U.S. EPA WaterSense Specifications for Tank -type Toilets. ❑ 4.303.1.3.2 Urinals. The effective flush volume of urinals shall not exceed 0.5 gallons per flush. ❑ 4.303.1.3.1 Single Showerheads. Showerheads shall have a maximum flow rate of not more than 2.0 gallons per minute at 80 psi. Showerheads shall be certified to the performance criteria of the U.S. EPA WaterSense Specification for showerheads. ❑ 4.303.1.3.2 Multiple Showerheads serving one shower. When a shower is served by more than one showerhead, the combined flow rate of all showerheads and/or other shower outlets controlled by a single valve shall not exceed 2.0 gallons per minute at 80 psi, or the shower shall be designed to allow only one shower outlet to be in operation at a time. ❑ 4.303.1.4.1 Residential lavatory faucets. The maximum flow rate of residential lavatory faucets shall not exceed 1.5 gallons per minute at 60 psi. The minimum flow rate of residential lavatory faucets shall not be less than 0.8 gallons per minute at 20 psi. ❑ 4.303.1.3.2 Lavatory faucets in common and public use areas. The maximum flow rate of lavatory faucets installed in common and public use areas (outside of dwellings or sleeping units) in residential buildings shall not exceed 0.5 gallons per minute at 60 psi. ❑ 4.303.1.4.3 Metering faucets. Metering faucets when installed in residential buildings shall not deliver more than 0.25 gallons per cycle. ❑ 4.303.1.4.4 Kitchen Faucets. The maximum flow rate of kitchen faucets shall not exceed 1.8 gallons per minute at 60 psi. Kitchen faucets may temporarily increase the flow above the maximum rate, but not to exceed 2.2 gallons per minute at 60 psi, and must default to a maximum flow rate of 1.8 gallons per minute at 60 psi. 4.303.2 Standards for plumbing fixtures and fittings. Plumbing fixtures and fittings shall be installed in accordance with the California Plumbing Code, and shall meet the applicable standards referenced in Table 1401.1 of the •1� California Plumbing Code. Page 2 of 5 CalGreen 2014.doc revised 01/15/14 Page 3 of 5 CalGreen_2014.doc revised 01/15/14 4..304.1 irrigation controllers. Automatic irrigation systems installed at the time, of final inspection shall be weather -based. ❑ 4.304,1.1 Controllers shall be weather- or soil moisture -based controllers that automatically adjust irrigation in response to changes in plants' needs as weather conditions change. T I� ❑ 4.304.1.2 Weather -based controllers without integral rain sensors or communication systems that account for local rainfall shall have a separate wired or wireless rain sensor which connects or communicated with the controller(s). Soil moisture -based controllers are not required to have rain sensor input. wilt, M E Ivi EVA I A N UTIM I IQ 0 wil 0 1 IIII- WSJ :8 AMIALS11:4 OMM /, DEEP,, NO 011 4.406.1 Rodent proofing. Annular spaces around pipes, electric cables, conduits, or other openings in plates at exterior walls shall be protected against the passage of rodents by closing such openings with cement mortar, concrete masonry or similar method acceptable to the enforcing agency. /ME/ �,i///0" ®r 0 / r r/ 4.408.2 Construction waste management plan. Where a local jurisdiction does not have a construction and demolition waste management ordinance, a construction waste management plan shall be submitted for approval to the enforcing agency. r / 4.410.1 Operation and maintenance manual. At the time of final inspection, an operation and maintenance manual shall be provided to the building occupant or owner. �/,i // /,i,, �, /. 4.503.1 General. Install only a direct -vent sealed -combustion gas or sealed fireplace, wood -burning or a sealed woodstove. / r� / , r /i iii. / 4.504.1 Covering of duct openings and protection of mechanical equipment during construction. Duct openings and other related air OX distribution component openings shall be covered during construction. 4.504.2.1 Adhesives, sealants and caulks. Adhesives, sealants and caulks VOC toxic limits. shall be compliant with and other compound 4.504.2.2 Paints and coatings. Paints, stains and other coatings shall be compliant with VOC limits. 4.504.2.3 Aerosol paints and coatings. Aerosol paints and other coatings shall be compliant with product weighted MIR Limits for ROC and other toxic ❑X ml„ compounds. Page 3 of 5 CalGreen_2014.doc revised 01/15/14 4.504.2.4 Verification. Documentation shall be provided to verify that compliant VOC limit finish materials have been used. 4.504.3 Carpet Systems. Carpet and carpet systems shall be compliant with M\7 ra( Y51 VOC limits. 4.504.4 Resilient flooring systems. Eighty (80) percent of floor area receiving resilient flooring shall comply with the VOC-emission limits defined in the Collaborative for High Performance Schools (CHPS) Low -emitting ❑X 471 Materials List or be certified under the Resilient Floor Covering Institute (RCFI) FloorScore program. 4.504.5 Composite wood products. Particleboard, medium density fiberboard (MDF), and hardwood plywood used in interior finish systems shall ❑X comply with low formaldehyde emission standards. 4.505.2 Concrete slab foundation. Required vapor retarders and capillary breaks are also required to comply with CalGreen Section 4.505.2.1. 4.505.3 Moisture content of building materials. Moisture content of building] materials used in wall and floor framing is checked before enclosure. y� / r r �. 4.506.1 Bathroom exhaust fans. Exhaust fans which terminate outside the building are provided in every bathroom. ®r / 4.507.2. Duct systems are sized and designed and equipment is selected using the following methods: 1. Establish heat loss and heat gain values according to ACCA Manual J or �r equivalent. 2. Size duct systems according to ACCA 29-D (Manual D) or equivalent. 3. Select heating and cooling equipment according to ACCA 36-S (Manual S) or equivalent. RIM 9:101 Y_A1 0 1 ki RW IM ZKOINY11 I! 702.1 Installer training. HVAC system installers are trained and certified in the proper installation of HVAC systems. 702.2 Special inspection. The Licensed Professional responsible to verify CALGreen compliance is qualified and able to demonstrate competence in the [X] discipline they inspect and verify. i rrr , r r / f,/ c / i. � / / /.,, .... 703.1 Documentation. Verification of compliance with CALGreen may include construction documents, plans, specifications, builder or installer certification, inspection reports, or other methods acceptable to the enforcing agency which show substantial conformance. Implementation verification shall be submitted to the Building Department after implementation of all required measures and prior to final inspection approval. Page 4 of 5 CalGreen 2014.doc revised 01/15/14 Project Name: Project Address: Project Description: CALGREEN SIGNATURE DECLARATIONS Asao Residence 10540 Chase Drive Cupertino, CA Home Addition SECTION 1 — DESIGN VERIFICATION Complete all lines of Section 1 —"Design Verification" and submit the completed checklist (Columns 1 and 2) with the plans and building permit application to the Building Department. The owner and design professional responsible for compliance with CalGreen Standards have revised the plans and certify that the items checked above are hereby incorporated into the project plans and will be implemented into the project in accordance with the requirements set forth in the 2010 California Green Building Standards Code as adopted by the City of Cupertino. t X�- Owner's Signature Print) Design Professional's Signature Design Professional's Name (Please Print) Signe of License�rofessional responsible for CalGreen compliance Name of Licerise Profestional responsible for CalGreen compliance (Please Print) Darrel@builders-energy.net Email Address for License Professional responsible for CalGreen compliance SECTION 2 — IMPLEMENTATION VERIFICATION V/1 <, Date Date 0512012014 Date 408-718-1908 Phone Complete, sign and submit the competed checklist, including column 3, together with all original signatures on Section 2 to the Building Department prior to Building Department final inspection. I have inspected the work and have received sufficient documentation to verify and certify that the project identified above was constructed in accordance with this Green Building Checklist and in accordance with the requirements of the 2010 California Green Building Standards Code as adopted by the City of Cupertino. r Signature of License Professional responsible for CalGreen compliance 6ate L. 10-f -('06 -99a Name of License Professional responsible for CalGreen compliance (Please Print) Phone 6A;C (?_ )9�.,i!dens–EN- ,'�J of, - Email Address for License Professional responsible for CalWen compliance Page 5 of 5 CalGreen 2010.doc revised 08/27/11