Loading...
14100128LA CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10615 RANDY LN CONTRACTOR: P & T GENERAL PERMIT NO: 14100128 CONSTRUCTION CO INC OWNER'S NAME: ANDREW MAUFFET-SMITH PO BOX 4786 DATE ISSUED: 10/22/2014 OWNER'S PHONE: 4082244655 SAN JOSE, CA 95150 PHONE NO: (408) 2244655 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL . •,, '!; REMODEL KITCHEN (216 SQ FT); MASTER BATH (169 SQ License Classes Lic. 4 �`j� j FT); REMOVE AND REPLACE (7) WINDOW; REPLACE (2) Contracto��. �.-,� �a. /�.� Date f � 2 Z�/ WATER HEATER; ADD SKYLIGHT IN M.SUITE 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: 1 have and will maintain a certificate of consent to self -insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the Sq. Ft Floor Area: Valuation: $170000 performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance, as provided for by ection 3700 of the Labor Code, for the performance of the work for which this permit is issued. APN Number: 31602049.00 Occupancy Type: APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT RESAF WORK IS NOT STARTED correct. I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS F PERMIT ISSUANCE OR to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save 180 DAYS FROM LAST CALLED INSPEiCTION. indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the 2 granting of this permit. Additionally, the applicant understands and will comply Issued by: Date: — with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signa ure .f �� Dat !% RE -ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, 1 agree to remove all new materials for inspection. ❑ OWNER -BUILDER DECLARATION Signature of Applicant: Date: I hereby affirm that 1 am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER 1, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) I, as owner of the property, am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project (Sec.7044, Business & Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the declarations: Health & Safety Code, Section 25532(a) should I store or handle hazardous I 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 Owner or authorized age n� Date permit is issued., I certify that in the performance of the work for which this permit is issued, l 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 CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code, I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save ARCHITECT'S DECLARATION indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section Licensed Professional 9.18. Signature Date CUPERTINO CONSTRUCTION PERMIT APPLICATION(�`2`3 COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION ` 'V 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 `L (408) 777-3228 • FAX (408) 777-3333 • building6a cupertino. erq 1 ❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION / TI ❑ REVISION /DEFERRED ORIGINAL PERMIT N PROJECT ADDR S APN 0 Lao OWNE NAME PHONE ,sy �j� E-MAIL L,Ar STREET ADDRESS CITY, STATE, ZIP FAX CONTACT NAME PHONE , ..., E-MAIL STREETADDRESS CITY, STATE, ZIP FAX ❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LIC SE NU LICENSE TYPE BUS. IC k COMPANY NAN�U,- „ E-MAIL FAX °�"� STREET A JFESS y� + CITY, STATE, ZIP, / PHONE ARCMTECT/ENGINEER NAME LICENSE NUMBER BUS. LIC k COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORKe. .�4 Na, Ir- EXISTINGUSEr PROPOSED USE CONSTR TYPE I STORIES USE TYPE OCC. SQ.FT. VALUATION ($) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DTTACH „,•'-'•-` `IT --•n„. ❑ 9 DWELLING UMTS: IS A SECOND UNIT ❑ YES BEINGADDED? ❑NO SECOND STORY ❑ YES ADDITION? []NO d PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YES EIVFD BY. OTAL VALUATION: PLANNING APPL # F ­)NO PLANNING APPROVAL LETTER EICHLER HOME? ❑ NO {t �y, By my signature below, I certify to each of the following: I am the property owner Or authorize -ent to ac on the property Owner's behalf. I halve read this application and the information I have provided is correct. I have read the Description of' York and v is accurate. I agree to comply with all applicable local ordinances and state laws building I authorize representatives of Cupertino to enter the above -identified property for inspection purposes. to��� Signature of Apcant/Ageting mconstruction. p Date:�r� f' SUPPLEMENTAL INFORMATION REQUIRED `s P nN CMCK TYPE ROUTING`SLIP OVEKTIIIrCQIINTER BUILDING PL AN REVIEW — New SFD or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to Issuance of building permit for new building. pPLANNING PLAN RE VIEW ❑; / ^J jr ❑K Commercial Bldgs: Provide a completed Hazardous Materials Disclosure STANDARA �r, PUBLIC WORKS'-'' _ form if any Hazardous Materials are being used as part of this project. ❑ ❑.FIRE Copy of Planning Approval Letter or Meeting with Planning prior to LARGE i i � r ❑ "T7AJOR REPT © submittal of Building Permit application. r SAINT A$Y $EV�'1;R DISTRICT =. � C�,EiVVtRO1VMENTAI,�HEALTII �' BldgApp_201 J.doc Devised 06/21/11 it CITY OF CUPERTINO FM -75 FEE ESTIMATOR - BUILDING DIVISION Plumb. Plan Check 0.0 hrs ADDRESS: 10615 randy In DATE: 10/2212014 REVIEWED BY: Mendez Other Plumb Insp. 0.0 E17___ APN: BP#: �`7���Q VALUATION: 1$170,000 °PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration /Repair PRIMARY SFD or Duplex USE: Suppl. PC Fee: Q Reg. Q OT PENTAMATION 1 R3SFDREM PERMIT TYPE: wORK remodel kitchen 216 sq ft); Master bath 169 sq ft); remove and replace 7 window; replace 2 water SCOPE heater; add skylight in m.suite; Plumb. Plan Check 0.0 hrs $0.00 Plumb. Permit Fee: 1PPERMIT Other Plumb Insp. 0.0 E17___ NOTE: This estimate does not include fees due to other Departments (I e. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.). These fees are based on the preliminary information available and are only an estimate. Contact the Dept for addn'l info. FEE ITEMS (Fee Resolution 11-053 Eff: T'1!13) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 216 s.f. $645.00 Remodel, Kitchen (<=300 sf) IREMRESKIT Suppl. PC Fee: Q Reg. Q OT 0.0 hrs $0.00 PME Plan Check: $0.00 LLLs. f. $645.00 Remodel, Bath (<=300 st) 1REMRESBAT Permit Fee: $0.00 Suppl. Insp. Fee:Q Reg. Q OT 0.0 hrs $0.00 = # Window / Sliding Glass Door $431.00 1WIAIREP Replacement PME Unit Fee: $0.00 PME Permit Fee: $48.00 = # $58.00 Plumbing IPRrvHEATR Water Heater Administrative Fee: 1ADMIN $45.00 Q Work Without Permit? 0 Yes (j) No $0.00 Advanced Planning- Fee:$0.00 Select a Non -Residential Building or Structure i Travel Documentation Fee: ITRA VDOC $48.00 Strong Motion Fee: IBSEISMICR $22.10 Select an Administrative Item Bldg. Stds Commission Fee: IBCBSC $7.00 SUBTOTALS: 1 $170.101$1,779.00 TOTAL FEE; $1 949.10 Revised: 08/20/2014 w � zp O O F- U)a tio 2 co 0 -4a p U H C O Q c� 0 ��m/ Q Ids 02 z W O > o �1 1 J a¢ LL LL O LLU ` U LU aL) LU U Z a U U- 0 O LU LU U O N O N 0 Lu 0 Ell o N O N c0 w tq U' Cl) N O A c v m Q, o � L4 C 7 c — �. Q Ln o c c C3 v n`, as W C3 � QJ is ar r C _r Q O Ol O r c N ao ° a` O •3 c g o Q , Q,c c cc ci L a2nti O o a° LL° ? 3� °pQ� (3 a o 40v n� Lr, o Q a C) v 3 r- ti ao u Wit, � a � � a•=., ate., Qi ° O U c ? v ZZZZ c �1 Qo 4_ ti w cc ° 3 Qj Q W O C Q O � N O E O_ C I OU o aQJQj 0 0 = U ( _0 G ° Qj° = ° v t vLn o o o = U rn IT in Q N a•=., N j C O `ti C Q O U a .a E A Z O O b LLO. U d CC o U al a o V O N z3`•'_ C n1 Qaai c IJ E U 3 an 0 d a h M 0 �l1 0 C j a C V) O h ° 0 3 Qj j Ql a h a1 V a CC U Ql 3` v •C O ° Ql Qi ° W 2 , 3 C Ln e v v a N Ql ar 46 a i p .p C U QJ a a s H C 3t:n O O H v QQj = h UQ,: e v 3 o v0 73 o a `^. Q 3 FS °o C :a C ° Qj v a a V,` o .� Qj a u o o o C, Ln O V) C3 = h a c o Ln a v vc °a 46 p°p O U V C Q C E Q 3Qj U U Q p O O 3 U U U Ql 6 � j V`O a O C R H a7 p •C LL, Q p ,O Q a a 'a aha., p rm� '6 v v C O a Y h ° O. " t Qi cc Qi �• N O. �^ v _ ." a W ." O vi - Ell o N O N c0 w tq U' Cl) N O A c v m V 0 d c O L4 C 7 c — �. Q c v O d O � d O LL v 01 O � QJ is ar r C _r Q O Ol O r c N o > m > z 3 L 0 A Ln O O O O 00 N 40v n� u Wit, N U C N U r- 0 0 O coo ( _0 O li c) O Q U rn IT in Q O Z ...i E A Z O O yw c O a a F al a o V ui Wd o o d Q U c IJ E U 3 an 0 d a ei o M 0 �l1 0 f� 0 O1 0 .•i M W Ln Z O O O �L N U) Q CIO 0 d O L.L O U r 0 x w w o w N i N O� O J r Q U w a O U O L E UP D cm C E 2 Q c7 O N aw C w c CL E U 0 c aw 'O aw cc m O N v ~ E >+ >+ >+ c c c O v O O O (n cn cn m m L N L L L L L Q Q Q y O ~ cr ar W _ D M O Cl) O 7 O C) v a° — v o Q Q x C N Maj �t v v c v n CU c CC C) Q N M �Y 0 C> r- N 1l_ ,� M O M 6 O O 6l O 0 c oa 0 o v c o c o c U C C C lD 0 w Y :3 > f�0 U � O M O) M r- a m 'i Ln E .c w U U O U O ou O CL c Ln - - - r - O Ln a s i O m d -C ` N u V N N N N .N. J N � E d -0 -0 -0 O a, a N C) _T O N cu Z L a O — O z LL 0 J Q rl \ m O � r m c7 O N aw C w c CL E U 0 c aw 'O aw cc m O N LL i:z, Lf) v - O O � m J � Q pQ CL LL U W Z Co w CV Q � ON O Co Q � U 0 C O A� _W 'LL v/ C O LL! (O Q N LL 0 w O = Z v p = o ~ z N O C p O � L L H C U Q 2 C LU M U i _ Z a < a J 0 *' Q�>u af LL (A z cu Er w 0 O > w O LL .� O F- v m � C J Q C LL x LL L E O L)U z' A V w CU d I d w v a e 0 v Q O M. o 0) m N C, - O !a m C m a c N 3 O N N U O E O N E @ O U r E Cs m E ~ w @ m C C a) L v p U a) 0) O C N ~ O U vu 41 — C bb a� � @ O C O c C C O ti O '- O m N O @ N C cu U L N Y C Q @ E O N N Y O N F E m Ln 7 w Lu C c Q v O O 4'M Q 0 CU u o 4) ! O C E O oo a` O p � D X W C) o av W 3 o u O W cu m J a w c J Q h > W O C N _O a Q N f6 U Vr O C C: � p C Z N s O N o Y N L Y O v t7 O 0 E v Z U) O C v E C Q a cuX F- N O C: N -=fu o N O O C > p j ZLU @ r m V C N 00 Y C O 6 r -I r`I Q 0 C >. O NLnu F- u N O O Ln o 6 0 a m o c ° .� @ Y N - m c o � a O u U 5 v- O Y Y ia V O O j o� d U Z > C Yo s Q O u a 3 ? U m > C. C Q) n m E L OD u U N C O O C h L M p UD E NC N v x Lu m ? m LJ C 0 ? O U U N o +_' v v -a g a �a v > a O m W u _0 LLO -0@ -0 'j 0 ti o O •- s n rn 0 O o OGcu 0m uj z 0 u O (U Z • • 0 v Q O 0) m C m N O E O O U r E m O m a) L a) 0) O C O O C O m N m L N O Ln c O O 4'M Q u o 4) ! � E D X W 3 O J J Q h W C _O Q N Y + Vr O C C: Z N O N L t7 0 Z U) O v Q a F- C: o W O .2 LO ZLU @ r LL Y 6 Q 0 v } / ¢ 9 \ / \ ] k c 0 � : W > � ■ LL c § w _ W § 2 � 2 \ LT- V) 0 ƒ 2 e 0 D 07 z k / S LLJ � g c Z / / c - \< a (D (D > \ / E < } o LL 9 cu mom- > � /� -T- Ku�/\) LL LA} C) LUma.M - \ / \ u Ln _ 5 G z E $ 0 $ e / Li- u u § E § - u5a LUtn e ) U rn Gƒ V) 2 0 / ]\® cu \ \ 0 ° LL \ Z / / \ 1-4 \ \ / \ E=u 2 /§\ I C13/25 / � i- 0 04 / 2 2 0 % % % \ V 6 2 2 2 = a 2 2 c _0§ m 2 $) 'C: 7 7 = 7 m ° < k « # # \ « » $ $ / / % $ $ $i m aj % % t b % I ` & b cu- Z 2\, \ ƒ < 2k \ \ \ § e - - - « � / $ J $ 7 \ \ \ \ \ \ < Lr))¥) % { E \ 7 \ LLJ0 < < 2 x « ® d \ \ j / \ E < } # A \ E / y f w}_ E 0 q /� C:\ 2 o $ I $ { 7 z / $ } qrn \ �e\ u \ z C 9 2 2 txo CL m / \ aj- z ui ko = a _ _ \ W —r - Lr) L- O O H Ll1 J � Q h0 m -4 d L.L `f u O N O N O C O v U1 L1 W v 0 z O (�O L F- V) C U _O C +� U U Z CU CL N a c � d m a+ E C O v u - L.L N Q w N M Q .= C L4� 2 L -L 'L E N ? W cu a u a w O ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ -O - y '> c> N u ❑ u ❑ u ❑ u ❑ u ❑ u ❑ u ❑ u ❑ u ❑ u ❑ u ❑ u ❑ u ❑ u ❑ u ❑ CU a E N v-. O U0 w O w = = E O v o -0 -0 -0 -0 -0 -0 -0 -0 -0 -0 -0 -0 c c ® EI ❑ ❑ ❑ EI EI ❑ ❑ ❑ EI EI ❑ ❑ ❑ a -o v n O Y U N E v 'o m 'o 'o 'o m m m 'o m 'o 'o (o 'o No v w ® ❑ 11 11 11 El 11 ❑ ❑ ❑ ❑ ❑ J Q c m ai N L, U a) a� � C m Ou 'a ai vf4i o E v i Q C N O y ti Q U O u_ LO C Y Q aJ O O N u ucu s C O LL w a1 u x O E ^ aci o w N N Y w w > + c = fV 'n '^ c O m N Q 7 O ) Ln cu z E L ri u N v cu ,L- x v X p n 'v ai LU {/ > ai N n {i Ln Y o vI� N N Vf c c w v ai u ui a > E E ai (U j.a `J O 'O L H rL '7 w C ) . N .c Q 3 > Z vi E Y -O N O o C� O x xx to .O -j a. a O C (O U' U CO L C a1 C) -N � .0 E Z- > O a L E E c C - ° OW u �,�, () = oa v E U E w c l7 o v jr, V vT 2 Z -o -o u rn aE aj to to ++ LU a1 m y C C _ " - c cn v E ai .^ X x I (U a t' u axi a) N v W N v ami aL L LLJ N trio C N C - /a O tt- .- a) N Ev m oa o NY v -o c -o c c L o N v v v am' ai c - E 'c t9 � o w3� Y m N U Z U C O N O C N N oa U U O rl C ::) O ;a L C O 7 O a) E o S E E Q u v O O O Z o c 3 ' O o w o a o ,co cl CO y al E E ui of C C u C .0 m N X x '^ VJ 0 0 a v °i ar a '�-o.� N H Y C oa t0 u U / < 9 J % 0 6 \ ! / C 2 ■ Q !t � » � 2 LL U) 0 w § s 2 \ Cr ƒ � \ 2 ƒ Q) ocr - O m I 7 k / \ 2 2 0 Rg c LU k \ U, «±/ƒ �k29= 7 R \ E <�wLL ®amu O ƒ / (�§/ e e 0 Q ` / » ) < C \ 3 / \ 20-ouCL \ f « Ln > ¥ a u f _ -\)§ : Co - _ ±/ ^ ) ) f c - e7 e ± t / 2 L ƒ§J2 r/a, CU CL = i b / e I 0 ^ 2 > $ 3 \ k z 3 » 2 _ � \ % � g \_ ! G { ] \ j $ 0 �! }\ � \ ` ® CD & / R } \ E 3 (f«I-- � 3 cs� LM � } / §CU 0 \ < ® w � 0 ) :E@ Q)eee « MYQ f ��� k LLJ \( « 2 _ o R /Z \ \ Ln 'Z C) O �L U) J �a O U L.L U ofO w W z w Q z O LL Q U N C d Q w U a J N � G O>O Q�WLL z d W O O > w LL O Q v.— < _U LL (Y LL O LLI U) LAj U � L. W U cn C. U v a O N 0 N O r 0 u N C al L c bo a) m @ C E O 7 C U _ CL o o w E a1 a) -p 4 a, U v L) u Y u - C O c -Em c O 'a m a) v N a U E wN E O C -° OY u O u v C v n 0 0 m v _0 u v -p a)- — —a - — a j 7 _V M m 4 al al al N U a) U L ntio O E c O Y'^ c -p aO C m 0 _0-p E E �d0 N ai Y C E w ? O C 'O u C ^ a o 7 uo ai 'O O c L '6 m O u a N C C m � n aL aL an m N E cL m O cu E ai -p o Y -O al al �n '^ Y '� O" 0 ai 4 _� O� VTf L L to v O C .. v m O Y 3 ai 0 000 0 c ai 00 cuYO u ^ 'v, C Wbo V LO 00 O Co c C > O L�. W u 0D OC 'O N . -Ofo 3 O OO N v L N :a v NLO E N= ui OD m Y T v o N N N ui 6 00 u C_ a C 00 a1 ami [Y uQ) `O a) a N w 0 00 o m O t 00 a3+ u ,� c a L u v m 0 ._ t 0 o n u a 0p p m C ¢ o a w al —a O 7-0 a m m O E w O E E U p u U o m U 0 Y 2p m2 m m O N cu m d Y w -a! -0 m O- U al c m m u c w E Ou N w tf E a1 N 0 ..+ -r- a1 N N N U O C u U V m u u E p U Ou a1 a p i c +' is p al �O Y v 3 d Y C? u U ai v O •m a 0 m 3 m m .2 a M C E c v E -p c O 6/ — o v� p v (U: t' 'O '� U al C m E - v o a v o Zai a o 2 °° W CU E Cl U N H3 " m 2 LU E 3 F 3 � °1 a, o •�_ m p F u Z _u _ O fO p_ F— C 'z L' m _ U F_0 2 3_v N o m��Y VI u W ~ a1 m C lel 2 al `." Vf : a -- Q m Z p° C F v, N C O Y o c w E a Y Z U L O N O Z a m. t• ai a CL C: g u O N L Q n Y O a a`aii 0 c �o C m v Q m w p v U �— (D y. g v, m �, w o C Y v a v o -o -p o v c a) Q) c ai v: 'O `n N m e t0 O� Q C YO m '0 E v o T a> p 0 N x a, a) U v� c u Q) M Q ^ E C t0 a) O O C a c u m ai m w Q C — C LO 2 Y Z ° 00 o v Y u Z O 012 �. M NJ a1 m N C al m vi W O (� (� ,j/ Q ,0) Q F Y t; 5 C O O H a Y E�� v v 7 a o c E E — U Y .v o Y Q m c Y a w `a v o O O a N cZ U J Z m U O L U c E > m '— .., COv ,o O L m al L O L 3 _ H— -O F— U F— 3— O c C m C m V O > V a a) E C v m Q O w w a US a US E-6 v N �n N O o u° LU a u a r ni m c� Lr; (� ° a O 0 c!) N 6loz `aunt suuo_q aouegdwoo leguapisaa Edoz -uoilejodjoo uo!leogpaO pue 6uije21 aeloS ay; Aq pag!pao We sioloalloo ao/pue swa;s s u!leay-aalem aeloS -aoe s pauo!l!puoo u! Alaa!lua pasoloua si ao luepae;aa aoden a sapnloui soul uollons lueaabu;aa pue bu!d!d aalem pall!yo ao; uo!lelnsul :b'E(.00'096§ 'Pulm pue 'aoueualu!ew luaw !n a 'ajn;s!ow 'ly !funs o; anp leyl ulpnlou! 'a ewep woj; paloolold s! uo!lelnsul :VC . 0'096 'b'-E'OZ 6 algel spaepuelS;o sluawaa!nbai ay; s;aaw '!sd g 6< swa;sAs aalem joy ao swalsAs bu!leay o!uoapAy weals io; uo!lelnsu! ad!d :Z(O0-096§ 'V-0'096 uo!len 3 pue 9-0'096 algel of palelnsu! aq lleys duel aalem joy loaa!pui pue aoinos bu!leay uaamlaq palelnsui bu!d!d pue'(sau!I au!aq ao 'aalem pall!yo 'uo!;ons) bu!d!d walsAs 6u!IooO :Z(00'Og6§ '9-0'096 algel spiepuelS jad palelnsui aae sa ! aalem joy ;o suo!loas builelnomai ;o ylbual aa!lua pue 'swa;sAs bu!lelnoanoaa-uou 'duel aaleay aalem o; lsasolo sadld aalem ploo pue joy;o laa; g lsa13 :Z(D0'Og6§ -duel ayl;o aoua;xa ayl uo paleo!pui si amen -b uo!lelnsui leuaalui ayl aaat4m uollelnsui leuialu! 96-b ao uo!lelnsu! leuaa;xa Z 6-b aney siluel aalem loy loaa!pui aaylo io 'walsAs bu!leay-aalem aelos io; sluel dnNoeq ao sNuel a6eaols se yons 'swel abeaols Paagun :9 6(D0-096§ 'aaleaa ao Z 6-b jo aouels!sai lewiayl pa!lelsu! ue 6ulABt4 uo!lelnsui yl!m pa earn AIleuaa;xa aie paepuels lew!u!w leaapa; ay; ueyl aaleaa6 ou aoloe3 A6aau3 ue yl!m Palea saaleay aalenn se6 96eaoiS-.VA0-096§ ,(o)Z,06 6 uo!loaS;o sluawaann as Noeglas ay; laaw leyl slelsowaayl yl!m paddinbe aie swats s u!leaH :(!)0'09 6 VOOV ao VNOVAS '3VI:IHSV ql!M aouepa000e u! palelnoleo aie speol u!l000 ao/pue 6U1189H A00-09 6 -sialeay e s pue lood pue '(ldwaxe aae ay/nlg og 6 ueyl ssal awnsuoo leyl sly6!I lol!d yl!M uolloauuoo 96e110n Alddns leoploala ue yl!m saoue!Idde) saouegdde bu!N000 ployasnoy 'seoeuin; lealuao adAl-ue; :se6 leinleu ao; pal!q!yoid aae sly6!l lol!d bu!uanq Alsnonu!luoO :g-06 6§ 9 o E'0 6 6 ;o s;uawann as uo!;oauuoo dool uogelnonoaa pue 'amen uo!lelos! wn 'uoguanaa nnol;iloeq 'amen asealaa ane ayl laaw sa!ouedn000 le!luaP!saa 9slb-01H pue spun bulllamp ald!;lnw 6uuuas sdool uo!lelnonoaa 6u!leay aaleM :g(o)E'0 6 6§ .uo!ss!wwoO A6aau3 ayl Aq pa!p.}iao aie saouelldde palelnbaa aaylo Ile pue shone; 'speayaamogs `saaleay aalem 'luawdmba OVAH -.E'O 6 6§-0'0 6 6§ :sejnseegy wags g Buiqwnid pue BU14BOH JOIBM ` ufuollipuoa aaedg pal!q!yoa aie ` u!pl!nq ayl;o ap!slno ay; o; Paluan sl a!e aoopu! leyl uaynn 'lalloel xogaag a 6u!l000 ao; a!e aoopu!;o asn ay; pue sly6!l lol!d bu!uanq snonu!luoO :Z(a)O'096§ 'ao!naP loiluoo ane-uo!lsngwoo a ao pue as wep u!llg-;y g pue 'algeaa o 'alq!ssaooe Alpeei a yl!m a yl!m paddinba si pue eaae ui sayoui aaenbs x!s;seal le s! yoigm 'aNelu! me ap!slno uo!lsngwoo a aney sooeldaig ll!nq-tio;oe; ao tiuosew :9 6(a)0'096§ -xogaa!; ayl;o buivado anlua aql 6uijaAOO aooP sse16 ao lelaw algesolo a aney seoel eig ll!nq-Ajopel ao AjuoseVV :b'6 a 0096 :saanseeW o-1 seE) pue seoueff y seE) anf;eaoaaa `sa3ef aJfq -uogeioualap ly !I An pue atiewep leoisAqd wog; papajoid aq lleys pue you!/waa O -Z ueyl jaleajb ou si ales aoueawied aoden aaleM `%E'0 ueyl aaleaa6 ou si s6u!oe; lnoyl!m auole Iepalew uo!lelnsui 96pa qels ao; alea uo!ldiosge aaleM (1)0'096§ -96 ao tib sauoz alew!lO u! Pallelsul aauaeq ao en AjolepueVy : 0.096 ,wao3 2i ayl uo pag!oa s uaynn OOOZ 96-LL963 W1SV of BUIPJOOOe Pallelsu! pue 'palaqel 'pa;sal st deim 6uipjelaj a!y : 070§6 'aolopw lualen!nbe ao aooB awes;-poom pas!ea u! uo!lelnsu! 66-�J wnw!u!w :(p)0'09 6 . -aoloe;-n lualenmba ao gxZ u! 66-21) Ilem awea;-poom l xz w uo!lelnsu! E 6-b wnw!u!w :(o)O-Og 6§� 'ante^-�J palagel u !sap pailelsui sdainloe;nuew yl!m uuo;uoo lleys uo!lelnsui llg asoo-1 :(q)0`09-6 aoloe;-n lualen!nba ao uq!ao awea;-poonn u! uo!lelnsu! (suo!leaally/suo!l!PPV ao; 66-2! OE -2i wnw!u!Vy :(e)O-Og6 uao_� 2i 6-30 ay; uo pagpe s sl;ooH looO a jo uo!lellelsui ayl uagm (!)9,0 6 6§;o sluawaa!nbei ay; slaaw lepa;ew bugooa l000 ayl;o sanlen aoueloagaa aelos pue aouell!wa lewjay; aq-L:(!)9-06 6§ -wao3 8Z -3O uo apnlou! pue a aleolpul 'IeualeVy BuileInsul aoj spiepuelS slaaw pallelsui ao pagpa s uo!lelnsul : e 8'066 -paleas pue paNlneo ane suoileilaued pue slu!o.r lie 'pa pts-aayleann nae smopuim pue snoop aopa;x3 :L'0 6 6 e 6 6 6 -OL§ ;o sluawaam as ayl slaaw leyl uo!leillgu! pue ' OOHS lua!og}aoO u!e9 teal-! aeloS pagwao 'aoloe3-n pagpeo aql bugs!l laqel a aney (snnopu!nn Paleougej-pleg ldaoxa) slonpoid uo!leilsaua3 :b(e)9'066§ -a eNeal me l!wg of painloe;nuew ane saoe s pauol!puooun pue pauog!puoo uaannlaq snnopwnn pue saoot7 : 6(e)go 6 6 :saanseeW a olanu3 Buippe 'suet yl!m wao j 2i 6-3w ayl;o suo!loas algeolldde Ile l!wgnS -tiewwns s!yl w ao sluawnoop ayl ui aaagmasla umoys ane Aayl aaylaynn suo!leog!oads eouewao:pad luauodwoo wnw!u!w se sa!}ied lle Aq paaapsuoo aq lleys sawnlea; algeogdde ayl pue 'sluawnoop l!waad ay; olul paleaodaooul aq lleys AjewwnS saanseaw tiolepuew s!41 'molaq (,) Isualse ue yl!m pailiew swal! ayl apasaadns !legs (wao3 l-jb'-2i 6 -30 io `aab'-2iaoue!ldwoo jo aleog!laao ay; uo pols!l saanseaw A6jaua lua6uuls aaow •pasn yoeojdde aoue!ldwoo ay; ;o sselpie6aa 'pa;s!I saanseaw tiolepuew algeo!ldde lle yl!m Aldwoo lsnw spiepuelS ayl o;;oafgns s6u!pl!nq le!luapsai asp -moi :31ON OZ/OZ/06 ale(] aouap!sa�j yl!wS-la}4new aweN ;oa(oJd �-=IW (CIO � a ed ielivapisa�j :ANvwwnS S3NnSV3W ANOIV(INVW pt0o 'aunp swao_qaouegdwoj lepuepsea ELOZ -sjosuas AoueoeA Aq p@poiluoo jo Aoeog}a gbiy aq Ileys wooayleq yoea ui palle;sul 6uily6ii jaylo IIV '8 pue'woayleq pea ui pallelsui aq lleys aiieuiwnl AoeoUja y6iy auo 10 wnwiuiw y -y :sluawaiinbai 6uinnollol ayl laaw lleys swoayleq ui pallelsui 6upbr-i :9(�)0'05l§ -lauigeo paleuiwnll! 10 lool jeauii jad jannod 10 sllenn OZ ueyl ajow ou asn ileys slauiqeo o; iewalui si leyl 6uilgbil palielsui Ailu@ueuuad :17()1)0'056§ 'siawwip Jo sJosuas AOUeOeA Aq p@lloiluoo osle sl pue 'Z(1)0-096 uoiloaS ui suoisinoid alqeoildde ay; yliM aouep000e w polloi;uoo sl uayoli� ay; w buily6g lie uaynn luawaiinbei AoeoUjo gbiy luaoiad 09 ay; w01 ldwaxe aq Aew Zu 005'Z ueyl j@6jel shun bulllannp jot spell 006 Jo z11005'Z o; lenba jo ueyl ssal shun 6uillaMp jot slleM 09 o; df1 :NOIld3OX3 -Aoeoiga gbiy aq Heys suayolij ui buily6ii palle;sul Allu@uewied 10 abegenn pale] lelol ay;}o;uawad 09 }o wnwiuiw V:£(j)0-o56§ .Z(M)O,Ogi,§ 10 sluawaiinai ayl laaw lleys sloi;uoo pue saoinap uiyo;inns IlV Z 07056 ,(N)O,Ogl,§ 10 quawann ai alqeoildde ay;;aaw lleys 'suayo;iN ueyl jay;o swooi w 'sue;;sneyxa o; lei elui w;y i-j:d 6 �I 0'056 *sjosuas AoueOeA Aq papa;uoo aq o; paiin ai aq lou lleys slgbil Iy61N -(0)0'0£ 6 uoiloaS y;inn eouepj000e ui pauimalap se ue1 lsneyx@ jo aneuiwnl jad jannod 10 slleM aAU ueyl avow ou awnsuoo o; pale] aq ileys suet lsneyxa jo saneuiwnl palle;sui o; iei6alui sly6il ly6iu pue s;y6il;y6iu palle;sui Al;uauewJad 3601)0'056§ 'zH)l OZ Ueyl ssal ou Aouenbai1 lndlno ue aney lleys pue oiuoJloala aq lleys jaleaa6 jo sgeM £ 6 pale@ sdwel luaosajon11 jot slselle8 :a 6(N)0.056§ (o)o, OC iq Pagioa s se powunal@p aq lleys sanewwnI pal els ui Allueuewied 10 a elleM ayl O6 �I 0056 Glgeoil ase '8-0'09 6 3 -18V -L Jo V-0'096 3-18VJ- ql!m eouepj000e ui (I)0.056 uoiloaS yl!M aouegdwoo jot Aoeo!jja-enol io Aoeoilla-y6iy se pagisselo aq ileys saileuiwnl Pallelsul :17'6(N)0'056§ :soinseew uijy i -j lei;uopisaa 0'05 6 10 sluawann ai @Alen pue 'sJa;lg ' ui i '@lei nno11 ' uizis ownd ay; laaw luaw ine jo swats s lood leiluapisa�j :(d)o,056§ -spoped puewep ouloala Need -go buunp Aluo uni of pawwej of jo las aq o; sdwnd lie Molle liiM;ey; yo;inns awil a pue 'jalenn lood ay; xiw Alalenbape leyl Stalin leuol;oaJip aney lleys s100d :£(q)17'06 6§ -Janoo a aney ileys jaleay se6 jo dwnd leay a aney leyl s& -Fs jo slood joopinO :Z g 17'066 t uileay jelos ajnlnl jot suoiloauuoo n-liinq io 'sauil wnlaj pue uoilons paleoip@p jo 'jaleay pue jaliy uaannlaq @did 10 „9E Iseal le yl!M Pallelsui aq ileys luawdinbe 6uileay eds jo lood Auy :6(q)17.066§ 'ly il jol!d a jo bulleaq eouelsisai ouloala asn;ou lleys pue'suoilonjlsui builejado y;inn pjeo jo aleld 1oadjay;earn luouewied e'jaleay ayl 10 apislno palunow yolinns 110-uo ue'suoi;elnba�j Aouai0i43 eoueilddy ayl yl!M saildwoo leyl Aouaio}}a lewJ@yl a :aney o; paggpao aq Heys walsAs 6uileay eds jo lood Auy :(e)17"06 6§ :saanseegy;uawa in 3 pue suaalts S BuIIeGH e S PUe I00d TiepuelS leyl 10 17 uoiloaS w pa.iinai uoilelilu@n 6uipprn8 aloyM ay; 6uipinoid 10 poylaw algissiwiad a lou si uoi;ejado nnopwM -s6uipiin8 leguaplsa�j asi�j-nno-j u! A;ilenCj ny joopul aigeld000y pue uo!IelIJUan LOOZ-Z'Z9 PJ IDWIS 3`dZlHSV/ISNV10 sluawannbai ayl laaw pegs shun 6uillaMP IIV :(o)0-056§ 'saioojauui snojod aney;ouueo slonp algixal3 '06 Wo,og6 -leualew ayl 10 uoilepeiep asneo ueo leyl uoileipej Delos wool 6uipl@iys s@pinad pue luepielai jalenn si leyl buileoo a yliM paluied Jo @Hoge se paloaload aq pet's uoilelnsul weol jelnp@O 'puinn pue 'aoueualuiew lu@wdinba '@jnlsiow 'ly6iluns of anp leyl 6ulpnioui 'abewep woi1 paloaload aq lleys uoileinsul :6(w)0-056§ 'Sia wap palejado Allenuew 'elgiss@ooe Appeaj jo oilewolne jaylia aney coeds pauoil!Puoo buuuas swa;sAs 6uIleII;U@A i4!AeJO :9(w)0-056§ 'sic wep oilewolne jo 4e.ip req aney swals s ue1 lsneyx3 :L(w)0'09 6 -spueq nneip pue oilsew yl!M uoileuigwoo ui pasn si a el yons ssalun sadel jonp @Aisaype jeggnj joeq ylolo q:pm paleas aq lou pegs sluauodwoo rayl pue swalsAs lonp 10 sweas pue sluiof :aZ(w)0'05 6§ -slonp ayllo ease leuoiloes-ssojo ayl ui suoi;onpaj asneo of passaidwoo aq lou lleys smuopeid lioddns pue sail!Aeo ui pallelsui s;onQ -slonp uieluoo Aew swjolleid ljoddns pue sal;ineo 6uippn8 .pie pauogipuoo 6uiA@AUOo sol pasn aq lou pegs lonp aigixa6 jo pjeoq lonp 'le;aw laays paleas ueyl iaylo sleualew yliM palonjlsuoo jo paugap swnuald pue 'sjalpuey pie jol swjolleld lioddns 'sail!Aeo 6u!plin8 :6(w)0-056§ pasn aq ileys a el jo ysaw j@ylia pue oilsew 10 uoileuigwoo ayl 'youi 17/6 ueyl jejeoib s uiva o leas of pasn si a el jo of;sew 11 '£ZL -in }o sluawannbei ay; slaaw leyl lueiees iosa@e jo a 686 -in jo '17'686 -in ' 686 -in 10 sluawaiinlow aigeoildde ayl slaaw ;et'; walsAs ainsolo-lonp jaylo jo adel 'oi;sew yl!M paleas aq Heys sbuivadO -aoeds pauoi;ipum ui AIw!lua pasoloua a0 9-�j 10 lanai polie;sui wnwiuiw a of paleinsui aje swnuald pue slonp lie-wnlai pue lie-Alddns'9-9 piepuelS PUe 509 '1709 '£09 'Z09 ' 609 suogoaS OWO 10 sluawaiinbei ayl;aaw of palelnsui pue paleas aye 'palle;sui swnuald pue slonp walsAs uoi;nqulsip-lie IIV :6(w)0'056§ 17602/OZ/06 @ouapisagl yliwS-Iallnen aged aweN loafoJd H -:jW C 10 z a ed ieiivapisaij :ANvwwnS S3NnSV3W ANOiVCINVW MANDATORY MEASURES SUMMARY: Residential (Page 3 of 3) MF -1 R Project Name Date Mauffet-Smith Residence 10/20/2014 §150.0(k)6: Lighting installed in attached and detached garages, laundry rooms, and utility rooms shall be high efficacy luminaires and controlled by vacancy sensors. §150.0(k)7: Lighting installed in rooms or areas other than in kitchens, bathrooms, garages, laundry rooms, and utility rooms shall be high efficacy, or shall be controlled by either dimmers or vacancy sensors. EXCEPTION 1: Luminaires in closets less than 70 square feet. EXCEPTION 2: Lighting in detached storage building less than 1000 square feet located on a residential site. §150.0(k)8: Luminaires recessed into insulated ceilings shall be listed for zero clearance insulation contact (IC) by Underwriters Laboratories or other nationally recognized testing/rating laboratory; and have a label that certifies the luminaire is airtight with air leakage less than 2.0 CFM at 75 Pascals when tested in accordance with ASTM E283; and be sealed with a gasket or caulk between the luminaire housing and ceiling. §150.0(k)9A: For single-family residential buildings, outdoor lighting permanently mounted to a residential building or other buildings on the same lot shall be high efficacy, or may be low efficacy if it meets all of the following requirements: i. Controlled by a manual ON and OFF switch that does not override to ON the automatic actions of items ii or iii below; and ii. Controlled by a motion sensor not having an override or bypass switch that disables the motion sensor, or controlled by a motion sensor having a temporary override switch which temporarily bypasses the motion sensing function and automatically reactivates the motion sensor within 6 hours iii. Controlled by one of the following methods: a. Photocontrol not having an override or bypass switch that disables the photocontrol; or b. Astronomical time clock not having an override or bypass switch that disables the astronomical time clock, and which is programmed to automatically turn the outdoor lighting OFF during daylight hours; or c. Energy management control system which meets all of the following requirements: At a minimum provides the functionality of an astronomical time clock in accordance with Section 110.9; meets the Installation Certification requirements in Section 130.4; meets the requirements for an EMCS in Section 130.5; does not have an override or bypass switch that allows the luminaire to be always ON; and, is programmed to automatically turn the outdoor lighting OFF during daylight hours. §150.0(k)9A: For low-rise multi -family residential buildings, outdoor lighting for private patios, entrances, balconies, and porches; and outdoor lighting for residential parking lots and residential carports with less than eight vehicles per site shall comply with one of the following requirements: i. Shall comply with Section 150.0(k)9A; or ii. Shall comply with the applicable requirements in Sections 110.9, 130.0, 130.2, 130.4, 140.7, and 141.0. §150.0(k)9: For low-rise residential buildings with four or more dwelling units, outdoor lighting not regulated by Section 150.0(k)9B or Section 150.0(k)9D shall comply with the applicable requirements in Sections 110.9, 130.0, 130.2, 130.4, 140.7, and 141.0. §150.0(k)9D: Outdoor lighting for residential parking lots and residential carports with a total of eight or more vehicles per site shall comply with the applicable requirements in Sections 110.9, 130.0, 130.2, 130.4, 140.7, and 141.0. §150.0(k)10: Internally illuminated address signs shall comply with Section 140.8; OR not contain a screw -base socket, and consume no more than five watts of power as determined according to §130.0(d). §1'50.0(k)l1: Lighting for residential parking garages for eight or more vehicles shall comply with the applicable requirements for nonresidential garages in Sections 110.9, 130.0, 130.1, 130.4, 140.6, and 141.0. §150.0(k)12A. In a low-rise multi -family residential building where the total interior common area in a single building equals 20 percent or less of the floor area, permanently installed lighting for the interior common areas in that building shall be high efficacy luminaires or controlled! by an occupant sensor. §150.0(k)12B. In a low-rise multi -family residential building where the total interior common area in a single building equals more than 20 percent of the floor area, permanently installed lighting in that building shall: i. Comply with the applicable requirements in Sections 110.9, 130.0, 130.1, 140.6, and 141.0; and ii. Lighting installed in corridors and stairwells shall be controlled by occupant sensors that reduce the lighting power in each space by at least 50 percent. The occupant sensors shall be capable of turning the light fully On and Off from all designed paths of ingress and egress. 2013 Residential Compliance Forms June, 2014 0 �777!—k- � if CERTIFICATE OF VERIFICATION CF3R-MCH-20-H Duct Leakage Diagnostic Test (Pa f Project Name: Mauf -Smith sid ce Enforcement Agency: City of Cupertino Permit Number: 14100128 Dwelling Address: 10615 Randy ne City: Cupertino 777; 77 Zip Code: 014 A. System Information 01 Space Conditioning System Identification or Name System 1 02 Space Conditioning System Location or Area Served Down Stairs 03 Building Type from CF -1R Single family 04 Verified Low Leakage Ducts in Conditioned Space (VLLDCS) Credit from CF1R? No, credit is not taken 05 Verified Low Leakage Air Handling Unit Credit from CF1R? No, credit is not taken 06 Duct System Compliance Category Alteration MCH -20d - Complete Replacement or Altered Duct System B. Duct Leakage Diagnostic Test 01 Condenser Nominal Cooling Capacity (ton) 3.5 02 Heating Capacity (kBtu/h) 78000 03 Conditioned Floor Area served by this HVAC system (ft2) 1773 04 Duct Leakage Test Condition Test final 05 Duct Leakage Test Method Total leakage 06 Leakage Factor 0.15 07 Air Handling Unit Airflow (AHUAirflow) Determination Method Cooling system method 08 Measured AHUAirflow This field or section is not applicable 09 Calculated Target Allowable Duct Leakage Rate (cfm) 210 10 Actual duct leakage rate from leakage test measurement (cfm) 178 11 Compliance Statement: System passes leakage test 12 Notes: Registration Number: 215-A0029276C-M20000028-M208 Registration Date/Time: 2015-01-29 14:27:35 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2014-05-08 Report Generated: 2015-01-29 14:15:31 2013 Residential Compliance Schema Version: 0.51SDD CERTIFICATE OF VERIFICATION CF3R-MCH-20-H Duct Leakage Diagnostic Test (Page 2 of 3 ) C. Additional Requirements for Compliance 01 System was tested in its normal operation condition. No temporary taping allowed. 02 Outside air (OA) ducts for Central Fan Integrated (CFI) ventilation systems, shall not be sealed/taped off during duct leakage testing. CFI OA ducts that utilize controlled motorized dampers, that open only when OA ventilation is required to meet ASHRAE Standard 62.2, and close when OA ventilation is not required, may be configured to the closed position during duct leakage testing. 03 All supply and return register boots were sealed to the drywall. 04 Building cavities were not used as plenums or platform returns in lieu of ducts. 05 If cloth backed tape was used it was covered with Mastic and draw bands. 06 All connection points between the air handler and the supply and return plenums are completely sealed. 07 If the system complies using the Smoke Test method, the smoke test was conducted in accordance with the requirements of Reference Residential Appendix RA3.1.4.3.6. Systems that comply using smoke test shall not be included in sample groups for HERS verification compliance. 08 Verification Status: Pass - all applicable requirements are met 09 Correction Notes for this table: The responsible persons signature on this compliance document affirms that all applicable requirements in this table have been met unless otherwise noted in the Verification Status and the Corrections Notes in this table. D. Determination of HERS Verification Compliance All applicable sections of this document shall indicate compliance with the specified verification protocol requirements in order for this Certificate of Verification as a whole to be determined to be in compliance. 1 01 1 Complies: All specified verification protocol requirements on this document are met. Registration Number: 215-A0029276C-M2000002B-M20B Registration Date/Time: 2015-01-2914:27:35 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2014-05-08 Report Generated: 2015-01-29 14:15:31 2013 Residential Compliance Schema Version: 0.51SDD CERTIFICATE OF VERIFICATION CF3R-MCH-20-H Duct Leakage Diagnostic Test (Page 3 of 3) Documentation Author's Declaration Statement 1. 1 certify that this Certificate of Verification documentation is accurate and complete. Documentation Author Name: Documentation Author Signature: � � John Ambrose d hn c ?moose Company: Date Signed: AMBROSE INDUSTRIES 2015-01-29 14:16:40 Address: CEA/ HERS Certification Identification (if applicable): 490 SHAWNEE LANE 27875 City/State/Zip: Phone: SAN JOSE CA 95123 (408) 227-2885 Responsible Person's Declaration statement I certify the following under penalty of perjury, under the laws of the State of California: 1. The information provided on this Certificate of Verification is true and correct. 2. 1 am the certified HERS Rater who performed the verification Identified and reported on this Certificate of Verification (responsible rater). 3. The installed features, materials, components, manufactured devices, or system performance diagnostic results that require HERS verification identified on this Certificate of Verification comply with the applicable requirements In Reference Appendices RA2, RA3, and the requirements specified on the Certificate of Compliance for the building approved by the enforcement agency. 4. The information reported on applicable sections of the Certificate(s) of Installation (CF2R) signed and submitted by the person(s) responsible for the construction or installation conforms to the requirements specified on the Certificates) of Compliance (CF1R) approved by the enforcement agency. 5. 1 will ensure that a registered copy of this Certificate of Verification shall be posted, or made available with the building permit(s) issued for the building, and made available to the enforcement agency for all applicable inspections, I understand that a registered copy of this Certificate of Verification is required to be included with the documentation the builder provides to the building owner at occupancy. Builder Or Installer Information As Shown On The Certificate Of Installation Company Name (installing Subcontractor, General Contractor, or Builder/Owner): AMBROSE INDUSTRIES Responsible Builder or Installer Name: CSLB License: John Ambrose 801947 HERS Provider Data Registry Information Sample Group Number (if applicable): Dwelling Test Status in Sample Group (if applicable) Tested HERS Rater Information HERS Rater Company Name: Builders' Energy Services, Inc. Responsible Rater Name: Responsible Rater Signature: Darrel Kelly Responsible Rater Certification Number w/ this HERS Provider: Date Signed: CC2005655 2015-01-29 14:27:35 Digitally signed by CaICERTS. This digital signature is provided in order to secure the content of this registered document, and in noway implies Registration Provider responsibility for the accuracy of the information. Registration Number: 215-A0029276C-M2000002B-M20B Registration DatejTime: 2015-01-29 14:27:35 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2014-05-08 Report Generated: 2015-01-29 14:15:31 2013 Residential Compliance Schema Version: 0.515DD 4dS re 7 �- S - - Ter vAt-�- -4 , If I 5 - L toe, + )jq I nb 0,6 PLovol �t VN CA bcYftr� V -N W �'LO 6 lttec;+V- Lam, J Ncvx,<tA t,L- rv, -T. rt �. AL, vk vk C-3 Ta+ CP V -C- of I-n�tvN,O. orl , -r, 8 - ?.1- 1e4 -