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13030146�C CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20731 HANFORD DR CONTRACTOR: CAIXING XIE PERMIT NO: 13030146 OWNER'S NAME: CADGING XIE 20731 HANFORD DR DATE ISSUED: 09/11/2013 OWNER'S PHONE: 4082184090 CUPERTINO, CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL ff— CONSTRUCT 2 STORY SFDWL, 1 ST FLOOR 2,399 SQ FT, License Class Lic. # 2ND FLOOR 1,191 SQ FT, ATTACHED GARAGE 687 SQ FT, Contractor Date PORCH 74 SQ 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 performance of the work for which this permit is issued. Sq. Ft Floor Area: Valuation: $600000 I have and will maintain Worker's Compensation Insurance, as provided for by APN Number: 32633026.00 Occupancy '1') pc: Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct. I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save 180 DA OM LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities, judgments, against said City in consequence of the ���� 3 costs, and expenses which may accrue Issued by: Date: granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section RE -ROOFS: 9.18. Signature Date All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. ❑ OWNER -BUILDER DECLARATION Signature of Applicant: Date: _ I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER 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. 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 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 2255505, 25533, and 25534. Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized agent: Date: permit is issued. I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Worker's CONSTRUCTION LENDING AGENCY Compensation laws of California. If, after making this certificate of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must 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 CCUPERTINO & ��NEW CONSTRUCTION CONSTRUCTION PERMIT APPLICATION C COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION V 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building(a)cupertino.org ❑ ADDITION ❑ ALTERATION/ Ti ❑ REVISION/ DEFERRED ORIGINAL PERMIT H PROJECT ADDRESS O 7 3 / Y APN # 7 /_ ` �� - / }� 7( (�TF.- >Z t U {�� OWNERNAME i PHO �0�) L��= ILv C, X "A STREETADDRESS CITY, STATE, ZIP / FAX C �PVf1�NJ C % CONTACT NAME PHO V e/� 07 STREET ADDRESS CITY,STAT£dd +�/�j��/ FAX 1:1 OWNER 11 OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR 11//CONTRACTOR AGENT 11 ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME t LICENSE NUMBER LICENSE TYPE BUS. LIC # COMPANY NAME �jg' G/� /, ( l (/ E-MAIL FAX STREET ADDRESS __7ARCHITECT/ENGTNEER CITY, STATE, ZIP PHONE NAME LICENSE NUMBER BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK EXISTING USE PROPOSED USE CONSTR TYPE # STORIES USE TYPE OCC. SQ.FT. VALUATION ($) EXLSTG AREA NEW FLOOR AREA DEMO AREA TOTAL NET AREA ;- Z , L v D BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA /. P �I / ,. I l�J PORCH AREA A DECK AREA TOTAL DECK/PORCH AREA ETACH GARAGE AREA:�[]A /8 TTACH #DWELLING ITS: IS A SECOND UNIT ❑ YES SECOND STORY ❑ YES BEING ADDED? []NO ADDITION? []NO ( PRE -APPLICATION YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YES RECEI ED Y: TOTAL V LUATION: PLANNING APPL ❑ NO P ING APPROVAL LETTER EICHLER HOME? ❑ NO C� J c By my signature below, I certify to each of the following: I am the property owner or authorize a t to act on the property owner's behalf. I have read this application and the information I have provided is correct. I have 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 construction._Lautheyize representatives of Cupertino to enter the above -identified roperty for ' spection purposes. Signature of Applicant/Agent:� �'.=G Date: Z SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECK TYPE ROUTING SLIP ❑ OVER-THE-COUNTER _ffBUILDING _ New SFD or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building PLAN REVIEW permit for new building. ❑ EXPRESS PLANNING PLAN REVIEW _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure STANDARD ErPUBLIC WORKS form if any Hazardous Materials are being used as part of this project. ❑ LARGE IR DEPT _ Copy of Planning Approval Letter or Meeting with Planning prior to El MAJOR submittal of Building Permit application. SANITARY SEWER DISTRICT ❑ ENVIRONMENTAL HEALTH B1dgApp_2011.doc revised 06/21/11 CITY OF CUPERTINO 1 1 FFF FCTIMATnR - R1111,DING DIVISION LEIADDRESS: 20731 HANFORD DR DATE: 03/27/2013 REVIEWED BY: MENDEZ PC FEE ID APN: BP#: 03 / `VALUATION: $600,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: New Construction PRIMARY SFD or Duplex USE: 2nd Unit? Yes No PENTAMATION 1R3SFDW PERMIT TYPE: WORK CONSTRUCT 2 STORY SFDWL 1 ST FLOOR 2,399 SQ FT 2ND FLOOR 1,1191 SQ FT ATTACHED SCOPE GARAGE 687 SQ FT, PORCH 74 SQ OCCUPANCY TYPE: TYPE OF CONSTR. FLR AREA s.f. PC FEES PC FEE ID BP FEES BP FEE ID R-3 (Custom) II-B,111-B,IV,V-B 4,351 $3,072.76 IR3PLNCK $3,471.64 1R3INSP $0.00 PME Plan Check: $0.00 Permit Fee: $3,471.64 Suppl. Insp. Fee -0 Reg. Q OT 0,0 1 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 TOTALS: 4,351 $3,072.76 Construction Tax: IBCONSTAXR $3,471.64 # new units NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public wortcs, rtre, Sanitary newer "tatrtcy Of-reuvt , - s......,t -L.- ..tet:.,,:., ... ;..f .r..ntinn ava;tnhle and are only an estimate. Contact the Dept for addn'1 info. "[strict, etc . itt eae GGJ U/G u cu vs uw .u....... w. FEE ITEMS (Fee Resolution 11-053 Ef: 711112) ;61�ch. Plan ('heck Plumb. Plan Check Elec. Plan Check Ltech. T'� Plumb, Permit Fee: Elec•, Permit Fee: Alech. Insp, L,We,h. Other Plumb Insp. Other Elec. Insp. E:F Insp. Fee: Plumb. lisp. Fee: t;icc Insp. Fee: NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public wortcs, rtre, Sanitary newer "tatrtcy Of-reuvt , - s......,t -L.- ..tet:.,,:., ... ;..f .r..ntinn ava;tnhle and are only an estimate. Contact the Dept for addn'1 info. "[strict, etc . itt eae GGJ U/G u cu vs uw .u....... w. FEE ITEMS (Fee Resolution 11-053 Ef: 711112) ... ....».. .. FEE __� -- ---- --- - QTY/FEE - -- MISC ITEMS Plan Check Fee: $3,072.76 Select a Misc Bldg/Structure or Element of a Building Suppl. PC Fee: (j) Reg. Q OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $3,471.64 Suppl. Insp. Fee -0 Reg. Q OT 0,0 1 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Tax: IBCONSTAXR 1 # new units $ 29 Administrative Fec. E) Work Without Permit? 0 Yes (j) No $0.00 Advanced Planning Fee: 1PLLONGR $565.63 Select a Non -Residential Building or Structure 0 Travel Documentation Fees: Strong Motion Fee: IBSEISMICR $60.00 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $24.00 SUBTOTALS: $7,823.32 $0.00 TOTAL FEE: $7,823.32 Revised: 01/01/2013 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20731 HANFORD DR CONTRACTOR: CAIXING XIE PERMIT NO: 13030146 OWNER'S NAME: CADGING XIE 20731 HANFORD DR DATE ISSUED: 09/11/2013 OWNER'S PHONE: 4082184090 CUPERTINO, CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL El COMMERCIAL Er CONSTRUCT 2 STORY SFDWL, 1 ST FLOOR 2,399 SQ FT, License Class Lic. # 2ND FLOOR 1,191 SQ FT, ATTACHED GARAGE 687 SQ FT, Contractor --i Date PORCH 74 SQ I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business & Professions REVISION #1- CLARIFY SLAB ON GRADE RAISED FLOOR-ISSD Code and that my license is in full force and effect. 10/1/2013 I hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain a certificate of consent to self -insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. Sq. t Floor rea: Valuation: $600000 1 have and will maintain Worker's Compensation Insurance, as provide APN Number: 32633026.00 Occupancy Type: Section 3700 of the Labor Code, for the performance of the permit is issued. APPLICANT CERTIFICATI I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct. I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save 180 DAYS FROM LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the Issued b�/� �/ G/f Date' granting of this permit. Additionally, the applicant understands and will comply Y' with all non -point source regulations per th Cupertino Municipal Code, Section RE -ROOFS: 9.18. 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 Date: Signature of Applicant: I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) I, as owner of the property, am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project (Sec.7044, Business & Professions Code). 1 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 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 agent: Date: permit is issued. I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Worker's CONSTRUCTION LENDING AGENCY Compensation laws of California. If, after making this certificate of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must 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 F� AIL'17/ ('OAiCTDI CONSTRUCTION PERMIT ��NN APPLICAT �Ei�f51oN # COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING,pLVJSION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 DATE (408) 777-3228 • FAX (408) 777-3333 • building D-cupertino.org I. c I I A nnITION 1 I AI TFR ATION / TI IYk REVISION / DEFERRED ORIGINAL PERMIT # PROJECT ADD&FSs APN N OWNER NAMEC, PHONE C-400) STREET ADDRESS �•,7�' . p CITY, STATE, �C.J P�t�Tl�to (212) C(Z��0. FAX CONTACT NAME � PHONE Q� ^ Q , 1 `S E-MAIL Q V" G vlLt I STREET ADDRESS CITY, STATE, ZIP FAX ❑ OWNER WNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME /N r E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK .� m, V-, rca�l� �, Srecf ��bUQ EXISTING USE `� PROPOSED USE CONSTR. S p ,� TYPE _ j p # STORIES .y USE TYPE OCC. SQ.FT. VALUATION (S) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH ❑ ATTACH DWELLING UNITS: IS A SECOND UNIT OYES SECONDSTORY OYES BEING ADDED? ONO ADDITION? ONO PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YES RECEIVE Y: TOTAL V PLANNINGAPPL#' ONO PLANNING APPROVAL LETTER EICHLERHOME? ONO J" By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I h rovided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to uillCiiawconstruction. I au orize representatives of Cupertino to enter the above -identified property for inspection purposes. Signature ofApplicanUA ent: Date: SUPPLEMENTAL NFORMATION RE U DPLANCIIECKTYPE ROUTING SLIP ❑ BUILDING PLAN REVIEW _New SFD or Multifamily dwellings: Apply for demolition permit orOVER-THE-COCNTER existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUBLIC WORKS form if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FIRE DEPT _ Copy of Planning Approval Letter or MeetingwithPlanning prior to ❑ MAJOR ❑ SANITARY SEWER DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH B1dgApp_2011.doe revised 06/21/11 CUPERTINO CONTRACTOR / SUBCONTRACTOR LIST Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 Fax: 408-777-3333 JOB ADDRESS: �p`(3 Z/ PERMIT # OWNER'S NAME: PHONE # GENERAL CONTRACTOR: i t BUSINESS LI NSE # Z� ADDRESS: 3 y/ CITY/ZIPCODE: *Our municipal code requires all businesses working in the city to have a City of Cupertino b siness license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL Sl,;�CONTRACTORS HAVE OBTAINED A CITY F CU ERTINO BUSINESS LICENSE. Q / I 1 am not using any subcontracto !� (� Si ature Date Please check applicable subcontractors and complete the following information: Date SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring / Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Date CUPERTINO CONTRACTOR / SUBCONTRACTOR LIST Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 Fax: 408-777-3333 JOB ADDRESS: -3 PERMIT # (� OWNER'S NAME: PHONE # GENERAL CONTRACTOR: r o BUSINESS LICENSE # , ADDRESS: CITY/ZIPCODE: O -14 *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 Please check applicable subcontractors and complete the following information: Date V SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork , Cement Finishing Electrical p Excavation Fencing Cm o i Flooring / Carpeting 1' Linoleum / Wood Glass / Glazing Heating Insulation Landscaping l ,d at{ j> Lathing Masonry Painting /Wallpaper PavingrinA�Isj-c��IA Plastering Plumbing ( k iV l -R oZ Roofing ? Yj 6 p- flmq I A Septic Tank 14 Sheet Metal Sheet Rock Yp ( ( �A Tile el7bolq- Date V1 RM go �y 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(afcupertino.org 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 ) I APN BP# OWNER NAME OWNER ADDRESS DESCRIPTION OF WORK: ' �X u 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.) ,Z.�_1. 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. X�_2. 1 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. �L 3. 1 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. \-4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. YL 5. I understand if I employ or otherwise engage any persons, other than California licensed 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. 6. 1 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. 'IL 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. ��8. 1 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 _�LL9. I 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. i'L10. I 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. _ZL_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. t-- 12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information 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 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 be required to be presented when the permit is issued to verify the property owner's signature. Property Owner's Signature: r� Date: �� ---------------------------------------------------------------------- ---------------------------------------------------------------------- (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 owner's signature. Property Owner's Signature: Date: OwnerBuilderForm 2010.doc revised 04/14/10 CUPERTINO PURPOSE: CALGREEN RESIDENTIAL CHECKLIST - MANDATORY ITEMS 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 • build inq(d�cupertino.orq l 3 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. Project Name: --,( 1 E 5 Project Address: 2 O '7 -�3 1 t—t �q A'R'$!lr°p? L-:'Dp. C Project Description: -'WO Is7-O#:;_1Y' &JC i01 -H d L) 71 F> Instructions: 1. The Owner or the Owner's agent shall employ a licensed professional expe4 ced with th7�a)fi r is Green Building Standards Codes to verify and assure that all required work described herein is properly planned and implemented in the project. 2. 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. 3. 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 Requirements Planning and Design - Site Development 4.106.2 Storm water drainage and retention during construction. A plan is developed and implemented to manage storm water drainage during 0 construction. El 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 1 of 5 CalGreen 2014.doc revised 01/15/14 A4.2 General 4.201.1 Low-rise residential buildings shall meet or exceed the minimum standard design required by the California Energy Standards. A4.3 WATER EFFICIENCY AND CONSERVATION Indoor Water Use 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 V. 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 01115/14 Outdoor Water Use 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. .. .4 MATERIAL CONSERVATION AND RESOURCE EFFICIENCY Enhanced Durability and Reduced Maintenance 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, Lt la concrete masonry or similar method acceptable to the enforcing agency. Construction Waste Reduction, Disposal and Recycling 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. Building Maintenance and Operation 4.410.1 Operation and maintenance manual. At the time of final inspection, an operation and maintenance manual shall be provided to the building MA occupant or owner. .. .5 ENVIRONMENTAL QUALITY Fireplaces 4.503.1 General. Install only a direct-vent sealed-combustion gas or sealed wood-burning fireplace, or a sealed woodstove. Pollutant Control 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 Q, 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 El.. 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 OX ❑ comply with low formaldehyde emission standards. Interior Moisture Control 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. Indoor Air Quality and Exhaust 4.506.1 Bathroom exhaust fans. Exhaust fans which terminate outside the �( I� building are provided in every bathroom. Environmental Comfort 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. M 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. INSTALLER AND SPECIAL INSPECTOR QUALIFICATIONS Qualifications 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 0 discipline they inspect and verify. Verifications 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 0['5 CalGreen 2014.doc revised 01/15/14 CALGREEN SIGNATURE DECLARATIONS Project Name: )(( S Rig tDlrs-ti) G Project Address: o`j 3 j f4 6 rJ 0J1-:> Project Description: 2 — -S TC)R—i(' xfie-U.) 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 OwrSer's Signatur Owner's (Please Print). I" rDesign-P-r�oi essional's Signature Design >sWe-ftiynal's Nar*,(Please Print) Signature of License Profession 1 respo ble for CalGreen compliance C -2 I =3 ?C Name of License Professional responsible for CalGreen compliance (Please Print) 6 ek T e V (�) 9 te a" I t rO ►M Email Address for License Professi al responsible for CalGreen compliance SECTION 2 - IMPLEMENTATION VERIFICATION Date 9 .-- i S — i4 - Date (Q-aP,)q q -C -',?q 5 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 2 alifornia Gre uilding Standards Code as adopted by the City of Cupertino. Ci --i K, iyC Signature of License Professional resp le for CalGreen compliance Date Name of License Professional responsible for CalGreen compliance (Please Print) Phone CA C-` t Y v\ -d Email Address for License Profe sional res nsible for CalGreen compliance Page 5 of 5 CalGreen 2014.doc revised 01/15/14 STATE OF CALIFORNIA ENVELOPE — INSULATION; ROOFING; FENESTRATION CEC-CF-6R-ENV-01 Revised 08/09 CALIFORNIA ENERGY COMMISSION INSTALLATION CERTIFICATE CF -6R -ENV -01 Envelope — Insulation; Roofin ; Fenestration (Page 1 of 4) Site Address:3 dInforcement Agency: Permit Number "W :�l If more than one person has responsibility for installation of the items on this certificate, each person shall prepare and sign a certificate applicable to the portion of construction for which they are responsible; alternatively, the person with chief responsibilityfor construction shall prepare and sign this certificate for the entire construction. All applicable Mandatory Measures with check boxes require to be checked to ensure the mandatory measures have been met. Description of Insulation 1. RAISED FLOOR Material: Brand Name: Thickness (inches): ( zx QP Thermal Resistance (R -Value): ❑ §150(d): Minimum R-13 iA sulation in raised wood -frame floor or equivalent U -factor. 2. SLAB FLOOR/PERIMETER F? —1 Cl Material: (A) r7 t91& , Brand Name: Thickness (inches): / , Thermal Resistance (R -Value): Perimeter Insulation Depth (inches): ❑ § 150(1): Water absorption rate for the insulation material alone without facings is no greater than 0.3%; water vapor permeance rate is no greater than 2.0 perm/inch and shall be protected from physical damage and UV light deterioration. 3. EXTERIOR WALL a. Insulation Type (e.x. Batt, Loose Fill, Spray Foam) a. Thermal Resistance (R -Value): R 2 � �A.� b.. Insu ation Type (e.x. Batt, Loose Fill, Spray Foam) Rl3 b. Thermal Resistance (R- e): Brand: Spray/Loose _ fill Installed Actual Thickness Spray/1 QQ'�Q Cont (inches):_ s mq r�,iNttll1 weight/ lb Manufacturer's installed weight per square foot to achieve Thermal esistaffce``(R-Val ❑ §150(c): Minimum R-13 insulation in wood -frame wall or equivalent U- ctor. Exterior Foam Sheathing (rigid Insulation) Material: stl x(p Brand Name: Thickness (inches) : Thermal Resistance (R -Value) : 4. FOUNDATION Material: Material: /p�F}}��' , � Brand Name: Thickness (inches): Thermal Resistance (R -Value): _ 5. CEILING Batt or Blanket Type: 13 A Tr Brand Name: Loose Fill Type: Thermal Resistance (R -Value): fz — 0 Spray Foam Type: Brand Name: Installed Actual Thickness (inches): jo" Contractor's min installed weight/W lb Manufacturer's installed weight per square foot to achieve Thermal Resistance (R -Value): ❑ §150(a): Minimum R-19 insulation in wood -frame ceiling or equivalent U -factor. 6. ATTIC ROOF INSULATION AND/OR ATTIC RADIANT BARRIER Material: p o pj Brand Name: Material: Brand Name: Thickness (inches): Thermal Resistance (R -Value): 72- --36 ❑ § 118(a): Insulation installed meets Standards for Insulating Material. 2008 Residential Compliance Forms August 2009 STATE OF CALIFORNIA ENVELOPE - INSULATION; ROOFING; FENESTRATION ;EC -CF -6R -ENV -01 (Revised 08/09) CALIFORNIA ENERGY COMMISSION INSTALLATION CERTIFICATE CF -6R -ENV -01 Envelope — Insulation; Roofing; Fenestration (Page 2 of 4) Site Address: Enforcement Agency: Permit Number: 2 0 3 1 H ate, "%ycl pr- r ❑ §150(g): Mandatory Vapor barrier installed in Climate Zones 14 or 16. ROOFING PRODUCTS (COOL ROOFS) §1510912 Check applicable box below if the newly installed roof is exempted from the roofing product "Cool Roof' requirements. Note: If any one of the boxes are checked below, the Aged Solar Reflectance and Thermal Emittance requirements for roofing products in §118(1) are not applicable. Do notfill table below. 13 Cool Roofs Not Required in Climate Zones 1-12, 14, and 16 with a Low Sloped. Less or 2:12 pitch. Cool Roofs Not Required in Climate Zones 1- 9 and 16 with a Steep -Sloped Roofs (pitch > than 2:12) and product unit weighting less than5lb/ft2. Other Exceptions ❑ Roofing area covered by building integrated photovoltaic panels and solar thermal panels are exempt from the above Cool Roof criteria. ❑ Roof constructions that have thermal mass over the roof membrane with at least 25 lb/ft2 is exempt from the above Cool Roof criteria. Area ft2 Roof Slope Product Weight I Aged Solar Thermal 030 CRRC Product ID Number' < 2:12 > 2:12 < 5lb/ft2 >_ Slb/ftz Product Type Reflectance3'4 Emittance 2 2 09 t S •— 0061' ❑ 15ir ❑ CONC . ❑4 O- iH G.90 3 L O'vc- ",6r LZ ❑ ❑ ❑ ❑ ❑4 ov'fC-11 4 1. CRRC-1 label information is available is on the package of the roofing product being installed and attach the CRRC label to this form. 2. Indicate the type of product is being used for the roof top, i.e. single ply roof, asphalt roof, metal roof, etc. 3. If the Aged Reflectance is not available in the Cool Roof Rating Council's Rated Product Directory then use the Initial Reflectance value from the same directory and use the equation (0.2+0.7(pj,jgot — 0.2) to obtain a calculated aged value. Where p is the Initial Solar Reflectance. 4. Check box if the Aged Reflectance is a calculated value using the equation above. To apply Liquid Field Applied Coatings, the coating must be applied across the entire roof surface and meet the dry mil thickness or coverage recommended by the coatings manufacturer and meet minimum performance requirements listed in § 11 8(i)4. Select the applicable coating: ❑ Aluminum -Pigmented Asphalt Roof Coating ❑ Cement -Based Roof Coating ❑ Other FENESTRATION/GLAZING Item Manufacturer/Brand Name GROUP LIKE RODUCTS Product U- factor Product SHGCt # of Panes NFRC Certified' z Total Quantity of Like Product (Optional) Area ft2 Add. Exterior Shading Dev. or Overhang Comments/ Location/ Special Features I 1L� i vavc► 0, la 030 2- 2 2 Ii 0, 'a,g O. Zl w �fi 3 4 ws 0,I)0 ov'fC-11 4 t/ 0.0 1 0'3(] 2 3rj 2 r_ C 5 6 7. 8. 1. Use values from a fenestration product's NFRC Certified Label. For fenestration products without an NFRC label, use the default values from Section 116, Table 116-A and 116-B of the 2008 EnerSy Efficiency Standards. 2. NFRC Label Certificates shall not be removed until the building inspector has verified the efficiency, Enter Yes or No. ❑ §116(a)l: Doors and windows between conditioned and unconditioned spaces designed to limit air leakage. ❑ § 116(a)2 and 3: Actual fenestration products installed are equivalent to or have a lower U -factor and/or a lower SHGC than that specified on the Certificate of Compliance (Form CF -1R). 2008 Residential Compliance Forms August 2009 STATE OF CALIFORNIA ENVELOPE — INSULATION; ROOFING; FENESTRATION 19, CEC-CF-6R-ENV-01 Revised 08109 CALIFORNIA ENERGY COMMISSION INSTALLATION CERTIFICATE CF -W -ENV -01 Envelope — Insulation; Roofing; Fenestration (Page 3 of 4) Site Address: Enforcement Agency: Permit Number: 2c5 -T3 I HAKj+-0?z D .pR . § 116(a)4: Fenestration products (except field -fabricated windows) have a label listing the certified U -Factor, certified Solar Heat Gain Coefficient (SHGC), and infiltration that meets the requirements of §10-111(a) § 117: Exterior doors and windows weather-stripped; all joints and penetrations caulked and sealed. DECLARATION STATEMENT • I certify under penalty of perjury, under the laws of the State of California, the information provided on this form is true and correct. • I am eligible under Division 3 of the Business and Professions Code to accept responsibility for construction, or an authorized representative of the person responsible for construction (responsible person). • I certify that the installed features, materials, components, or manufactured devices identified on this certificate (the installation) conforms to all applicable codes and regulations, and the installation is consistent with the plans and specifications approved by the enforcement agency. • I reviewed a copy of the Certificate of Compliance (CF -1R) form approved by the enforcement agency that identifies the specific requirements for the installation. I certify that the requirements detailed on the CF -1R that apply to the installation have been met. • I will ensure that a completed, signed copy of this Installation Certificate shall be posted, or made available with the building permit(s) issued for the building, and made available to the enforcement agency for all applicable inspections. I understand that a signed copy of this Installation Certificate is required to be included with the documentation the builder provides to the building owner at occupancy. 2008 Residential Compliance Forms August 2009 STATE OF CALIFORNIA ENVELOPE — INSULATION; ROOFING; FENESTRATION ;EC -CF -6R -ENV -01 (Revised 08/09) CALIFORNIA ENERGY COMMISSION INSTALLATION CERTIFICATE CF -6R -ENV -01 Envelope — Insulation; Roofing; Fenestration (Page 4 of 4) Site Address: Enforcement Agency: Permit Number: Company Name: (Installing Subcontractor or General Contractor or Builder/Owner) toe ( K :v) ---r 0a^� ogee l Responsible Pe on'sName, �� Respo . le Pers S' It CSLB License: v Date Signed: Position With Company (Title); Owvh e -v M 2008 Residential Compliance Forms August 2009 STATE OF CALIFORNIA RESIDENTIAL LIGHTING M7 EC -CF -6R -LTG -01 (Revised MOM CALIFORNIA ENERGY COMMISSION INSTALLATION CERTIFICATE CF -6R -LTG -01 Residential Lighting (Page 1 of 6 Site Address: Enforcement Agency: Permit Number: 1. Kitchen Lighting Does nroiect include kitchen liwhtinu7 Yes, com Tete section 1 ❑ No, go on to section 2 Yes §150(k)3: The wattage ofpermanently installed luminaires (lighting fixtures has been determined asspecified by §130(d). ❑ Yes >0 No §150(k)3: In the kitchen, are there electrical boxes finished with a blank cover or where no electrical equipment has been installed, and where the electrical box can be used for a luminaire or a surface mounted ceiling fan? If yes, the following row must also be es: ❑ Yes ❑ NA Wattage has been calculated as 180 watts of low efficacy lighting er blank electrical box. §150(k)8 Kitchen Lighting must comply with either method (a), (b), or (c) below: (a) All high efficacy luminaires Yes, complies because only high efficacy luminaires have been installed in the kitchen. ❑ No, complies with method b or (c). (b) >_ 50% watts used by high efficacy luminaires PT -yes, complies because at least 50% of the installed watts are from permanently installed high efficacy luminaires as demonstrated in the table below: Total A > Total B. ❑ No, complies with method (a) or (c). Fill out the following table if complying with either method (b) or (c). Table (h) Luminaire Type Efficacy High Low Watts x Quantity = High Efficacy Watts or Low Efficacy Watts FLU 6RfS<' x Lc = I �8 or I1JaADE Ste-' , ° ° 4 b x = or (2 O ❑ ❑ x = or ❑ ❑ x = or x — or Complies with method (b) if A > B Total: A: 3 > B: 2 (c) Additional Kitchen Low Efficacy Lighting ❑ Yes, complies because the kitchen lighting qualifies for additional low efficacy lighting and as demonstrated in table in (b) (above) and the table in (c) (below) that ( A + C) >_ B ❑ No, complies with method (a) or (b). Additional kitchen low efficacy lighting is available only if all of the following are true: ❑ Yes. All low efficacy luminaires in the kitchen are controlled by a vacancy sensor Dimmer energy management control system (EMCS) or a multi -scene programmable control system. ❑ Yes. Permanently installed luminaires in garages laundry rooms closets greater than 70 square feet and utility rooms are high efficacy luminaires AND are controlled by a vacancy sensor. Table (c) From the Table in b Use 50 W for dwelling units:5 2,500 ft' Use 100 W for dwelling units > 2,500 ft' Add Yes/No ? A B C A+C Is (A+Q >B? L. Lignting internal to t.;aamets Does project includes lighting internal to cabinets? 2008 Residential Compliance Forms August 2009 STATE OF CALIFORNIA RESIDENTIAL LIGHTING CEC-CF-6R-LTG-01 Revised 08/09 CALIFORNIA ENERGY COMMISSION INSTALLATION CERTIFICATE CF -6R -LTG -01 Residential Lighting (Page 2 of 6 Site Address: Enforcement Agency: Permit Number: ❑ Yes, complete section 2 ❑ No, go on to section 3 ❑ Yes, §150(k)9: Permanently installed lighting internal to cabinets uses < 20 watts of power per linear foot of illuminated cabinet. 2008 Residential Compliance Forms August 2009 STATE OF CALIFORNIA RESIDENTIAL LIGHTING CEC-CF-6R-LTG-01 (Revised 08/09) CALIFORNIA ENERGY COMMISSION INSTALLATION CERTIFICATE CF -6R -LTG -0I Residential Lighting (Page 3 of 6 Site Address: Enforcement Agency: Permit Number: 3. Installed Devices and Components Have Been Certified to the Energy Commission Does the project include any of the devices or components listed below? ❑ Yes, complete section 3 ❑ No, go on to section 4 ❑ Yes § 119 and § 150(k)7(F): Any of the following devices and components which have been installed have been certified to the Energy Commission according to the applicable provisions of § 119: All LED lighting systems that are classified as high efficacy, ballasts used in recessed luminaires, vacancy sensors (automatic off/manual on occupant sensors) dimmers track lighting integral current limiters and outdoor motion sensors 4. i.iuhtinu C"nntrnlc C'mmnlptp epetinn A Yes ❑ NA § 150(k)7A: Permanently installed low efficacy luminaires are controlled by switches separate from those controlling high efficacy luminaires. Yes ❑ NA § 150(k)7B: Exhaust fans with integral lighting systems are switched separately from lighting systems, OR have a lighting system that can be manually turned on and off while allowing the fan to continue to operate for an extended period of time. Yes ❑ NA § 150(k)7C: All permanently installed luminaires are switched with readily accessible controls that permit the luminaires to be manually switched on and off. Yes ❑ NA §150(k)7D: All lighting controls have been installed in accordance with the manufacturer's instructions. Yes ❑ NA §150(k)7E: All lighting circuits that are controlled by more than one switch, where a dimmer or vacancy sensor has been installed to comply with §150(k), no controls bypass the dimmer or vacancy sensor functions. 5. Luminaires (Lighting Fixtures) Dnec tha nrnirrt inrhvip the i etoll,t;. .,f.- 1,,.,,:...,:«o.. /:..,L.,.-,. .aa....-�o Yes, complete section 5 ❑ No, go on to section 6 Yes, high efficacy luminaire classification has been determined according to §150(k)1, and low efficacy luminaire classification has been determined according to §150(k)2. Yes ❑ NA § 150(k)4: Fluorescent lamps rated 13 watts or greater have an electronic ballasts having an output frequency no less than 20 kHz. V Yes ❑ NA § 150(k)5: Permanently installed night lights, and night lights integral to permanently installed luminaires or exhaust fans, contain only high efficacy lamps meeting the minimum efficacies contained in Table 150-C and do not contain a line -voltage socket or line voltage lamp holder, OR the night light is rated to consume no more than 5 watts of power and does not contain a medium screw -base socket. Yes ❑ NA §150(k)6: Lighting integral to exhaust fans, in rooms other than kitchens, meet the applicable requirements of §150(k). Yes ❑ NA Any electrical box finished with a blank cover or where no electrical equipment has been installed, and where the electrical box can be used for a luminaire or a surface mounted ceiling fan, has been treated as low efficacy luminaires for compliance with § 150(k). Does the project include any luminaires that are recessed into insulated ceilings? Yes, complete the rest of section 5 ❑ No, go on to section 6 Yes, §150(k)12: Luminaires that are recessed into insulated ceilings meet all of the following conditions: IR Yes, are listed, as defined in §101, for zero clearance insulation contact (IC) by UL or other nationally recognized testing/rating laboratory, and Yes, have labels that certify the luminaires are airtight with air leakage less than 2.0 CFM at 75 Pascals when tested in accordance with ASTM E283 (Exhaust fan housings are not required to be certified airtight), and �. Yes, are sealed with a gasket or caulk between luminaire housings and the ceiling, and all air leak paths between conditioned and unconditioned spaces have been sealed with a gasket or caulk. (including all exhaust fan housings), and C� Yes, allows ballast maintenance and replacement to be readily accessible to building occupants from below the ceiling without requiring the cutting of holes in the ceiline. 6. Indoor Lighting (any indoor room that is not a kitchen) Does the project include permanently installed luminaires in any room that is not a kitchen? 91 Yes, complete section 6 ❑ No, go on to section 7 Ellves ❑ NA §150(k)10: Permanently installed luminaires in bathrooms, garages, laundry rooms, closets > 70 82, and utility rooms are high /7 efficacy luminaires OR are controlled by a vacancy sensor. 2008 Residential Compliance Forms August 2009 STATE OF CALIFORNIA RESIDENTIAL LIGHTING CEC-CF-6R-LTG-01 Revised 08/09 CALIFORNIA ENERGY COMMISSION INSTALLATION CERTIFICATE CF -6R -LTG -01 Residential Lighting (Page 4 of 6 Site Address: Enforcement Agency: Permit Number: Yes ❑ NA §150(k)ll: Permanently installed luminaires located in rooms or areas other than in kitchens, bathrooms, garages, laundry rooms, closets, and utility rooms are high efficacy luminaires, OR are controlled by a dimmer switch OR are controlled by a vacancy sensor. 2008 Residential Compliance Forms August 2009 STATE OF CALIFORNIA RESIDENTIAL LIGHTING CEC-CF-6R-LTG-01 Revised 08/09 CALIFORNIA ENERGY COMMISSION INSTALLATION CERTIFICATE CF -6R -LTG -01 Residential Lighting (Page 5 of 6 Site Address: Enforcement Agency: Pcrmit Number: 7. Outdoor Lighting Does the project include any permanently installed outdoor liehtine? Yes, complete section 7 ❑ No, go on to section 8 Yes ❑ NA §150(k)13: Luminaires providing outdoor lighting, including outdoor lighting for private patios on low-rise residential buildings with four or more dwelling units, entrances, balconies, and porches, and which are permanently mounted to a residential building or to other buildings on the same lot are high efficacy luminaires OR are controlled by a manual on/off switch, plus a motion sensor not having an override or bypass switch that disables the motion sensor, plus one of the following three additional control methods: a. A photocontrol that does not have an override or bypass switch that disables the photocontrol; or b. An astronomical time clock not having an override or bypass switch that disables the astronomical time clock; or C. Energy management controls systems (FMCS) not having an override or bypass switch that allows the luminaire to be always on. ❑ Yes ❑ NA Exception 2: Low efficacy outdoor luminaires used to comply with Exception 1 to §150(k)13 are controlled by an override switch which temporarily bypasses the motion sensing function, and the motion sensor is automatically reactivated within six hours. The luminaire is controlled by a photocontrol, astronomical time clock, or EMCS as required by Exception 1 to §150(k)13. ❑ Yes ❑ NA Exception 3: There are permanently installed luminaires in or around swimming pools, water features, or other locations subject to Article 680 of the California Electric Code which do not need to be high efficacy luminaires. ❑ Yes ❑ NA §150(k)14: Internally illuminated address signs comply with §148, OR do not contain a screw -base socket and consume no more than 5 watts of power as determined according to § 130(d). ❑ Yes ❑ NA §150(k)15 Lighting for parking lots and carports with a total of 8 or more vehicles per site have lighting that complies with §130,132, 134, and 147. Lighting for parking garages for 8 or more vehicles comply with §130, 131, 134, and 146. If yes, the Nonresidential compliance forms must be submitted 8. Common areas of low-rise residential buildings Does the project include the installation of any luminaires in common areas of low-rise residential buildings? Yes, complete section 8 ❑ No, go on to section 9 Yes, §150(k)16: Permanently installed lighting in the enclosed, non -dwelling spaces of low-rise residential buildings with four or more dwelling units shall be high efficacy luminaires OR are controlled by occupant sensor(s) certified to comply with § 119(d). DECLARATION STATEMENT • 1 certify under penalty of perjury, under the laws of the State of California, the information provided on this form is true and correct. • I am eligible under Division 3 of the Business and Professions Code to accept responsibility for construction, or an authorized representative of the person responsible for construction (responsible person). • I certify that the installed features, materials, components, or manufactured devices identified on this certificate (the installation) conforms to all applicable codes and regulations, and the installation is consistent with the plans and specifications approved by the enforcement agency. • I reviewed a copy of the Certificate of Compliance (CF -IR) form approved by the enforcement agency that identifies the specific requirements for the installation. I certify that the requirements detailed on the CF -1R that apply to the installation have been met. • I will ensure that a completed, signed copy of this Installation Certificate shall be posted, or made available with the building permit(s) issued for the building, and made available to the enforcement agency for all applicable inspections. I understand that a signed copy of this Installation Certificate is required to be included with the documentation the builder provides to the building owner at occupancy. Company Name: (Installing Subcontractor or General Contractor or Builder/Owner) n 2008 Residential Compliance Forms August 2009 STATE OF CALIFORNIA RESIDENTIAL LIGHTING F1, CEC-CF-6R-LTG-01 Revised 08/09 CALIFORNIA ENERGY COMMISSION INSTALLATION CERTIFICATE CF -6R -LTG -01 Residential Lighting (Page 6 of 6 Site Address: Enforcement Agency: Permit Number: Responsible PeName- � +1� Responsle Person Si at'��j CSLB License: /� Date Signed: Position With Com any itle): l'2W `49 o" e 2008 Residential Compliance Forms August 2009 STATE OF CALIFORNIA DOMESTIC HOT WATER (DHW) GEC- CF-0R-MECH-01 Revised 08/09 CALIFORNIA ENERGY COMMISSION INSTALLATION CERTIFICATE CF-6R-MECH-01 Domestic Hot Water (DHW) (Pa e 1 of 3 Site Address: Enforcement Agency: Pcrmit Number: X7-731 Hfl1J�R(� 1�. 1. WATER HEATING SYSTEMS: Heater Type CEC Certified Mfr Name & Model Number Distribution Type (Std, Point -of- Use, etc) If Recirculation, Control Type # of Identical Systems Rated Input (kW or Btu/hr)(gallons) Tank Volume Efficiency (EF, RE)I Standby Loss (%), S-17010- Ar <5r. N o 1 4-01 otv Note 1: For small gas storage (rated input less than or equal to 75, 000 Btu/hr), electric resistance and heat pump water heaters, list Energy Factor (EF). For large gas storage water heaters (rated input of greater than 75, 000 Btu/hr), list Recovery Efficiency (RE), Thermal Efficiency, Standby Loss and Rated Input. For instantaneous gas water heaters, list the Thermal Efficiency and Rated Input. 2. Mandatory Measures TO COMPLY - ALL BOXES MUST BE CHECKED P§ 110-§ 113: Water heaters, showerhead and faucets are certified by the California Energy Commission. § 1500): Water System Pipe and Tank Insulation. And Cooling Line Insulation 11..c Storage tank insulation C]I A. Storage gas water heaters rated with an Energy Factor no greater than the federal minimal standard are externally wrapped with insulation having an installed thermal resistance of R-12 or greater; and TK B. Unfired storage tanks or other indirect hot water tanks have R-12 external insulation or R-16 internal insulation where the internal insulation R -value is indicated on the exterior of the tank. 2. Water piping and cooling system line insulation thickness and conductivity First 5 feet of hot and cold water pipes closest to water heater tank, non -recirculating systems, and entire length of recirculating sections of hot water pipes are insulated per Standards Table 150-13; and Pipe insulation for steam hydronic heating systems or hot water systems > 15 psi, meets the requirements of Standards Table 123-A. Insulation is protected from damage, including that due to sunlight, moisture, equipment maintenance, and wind. 2008 Residential Compliance Forms August 2009 STATE OF CALIFORNIA DOMESTIC HOT WATER (DHW) CEC- CF-6R-MECH-01 (Revised 08/09) CALIFORNIA ENERGY COMMISSION — INSTALLATION CERTIFICATE CF-611-MECH-01 Domestic Hot Water (DHW) (Pa e 2 of 3 Site Address; Enforcement Agency: = Number: ❑ § 151(f)8D: If indicated on the CF -IR, all hot water piping that runs from the hot water source to the kitchen fixtures is insulated per Standards Table 150-13. 3. Central Water Heating in Buildings with Multiple Dwelling Units (required for prescriptive) TO COMPLY - ALL BOXES MUST BE CHECKED All hot water piping in main circulating loop is insulated to requirements of § 1500) ❑ Central hot water systems serving six or fewer dwelling units which have (1) less than 25' of distribution piping outdoors; (2) zero distribution piping underground; (3) no recirculation pump; and (4) insulation on distribution piping that meets the requirements of Section 1500) ❑ Central hot water systems serving more than 6 dwelling units - presence of either a time control or a time/temperature control DECLARATION STATEMENT • 1 certify under penalty of perjury, under the laws of the State of California, the information provided on this form is true and correct. • I am eligible under Division 3 of the Business and Professions Code to accept responsibility for construction, or an authorized representative of the person responsible for construction (responsible person). • I certify that the installed features, materials, components, or manufactured devices identified on this certificate (the installation) conforms to all applicable codes and regulations, and the installation is consistent with the plans and specifications approved by the enforcement agency. • 1 reviewed a copy of the Certificate of Compliance (CF -1R) form approved by the enforcement agency that identifies the specific requirements for the installation. I certify that the requirements detailed on the CF -IR that apply to the installation have been met. • 1 will ensure that a completed, signed copy of this Installation Certificate shall be posted, or made available with the building permit(s) issued for the building, and made available to the enforcement agency for all applicable inspections. I understand that a signed copy of this Installation Certificate is required to be included with the documentation the builder provides to the building owner at occupancy. 2008 Residential Compliance Forms August 2009 STATE OF CALIFORNIA DOMESTIC HOT WATER (DHW) CEC- CF-6R-MECH-01 (Revised 08/09) CALIFORNIA ENERGY COMMISSION 7--" INSTALLATION CERTIFICATE CF-6R-MECH-01 Domestic Hot Water (DHW) (Pa e 3 of 3 Site Address: Enforcement Agency: Permit Number: Company Name: (Installing Subcontractor or General Contractor or Builder/Owner) We I ,� Vl i to 1�1� Ha�� U Vfo I Responsible Person's a Responsible Pe ' Sture: CSLB License: �� Date Signed: Position With Company itle): © . 2008 Residential Compliance Forms August 2009 STATE OF CALIFORNIA SPACE CONDITIONING SYSTEMS, DUCTS AND FANS CEC- CF-6R-MECH-04 (Revised 08/09) CALIFORNIA ENERGY COMMISSION _� , INSTALLATION CERTIFICATE CF-6R-MECH-04 Space Conditioning Systems, Ducts and Fans (Page 1 of 4) Site Address: Enforcement Agency: Permit Number: —1c7 -T3 1 . +-tA*I oRt�, DP . 11 1 Space Conditioning Systems Heating Equipment Equip Type (package- heat um CEC Certified Mfr. Name and Model Number ARI Reference Number 2 # of Identical Systems Efficiency (AFUE, etc.)• 3 (>_CF -1R value)4 Duct Location (attic, crawl- space, etc. Duct R -value Heating Load Btu/hr) Heating Capacity (Btu/hr CE -MAL * O,8 cowl Iz--E, CWT42AL 1 0,z, Anlc I--6 Cooling equipment Equip Type (package heat um CEC Certified Mfr. Name and Model Number ARI Reference Number 2 # of Identical Systems Efficiency (SEER and EER) 1'; (>_CF -1R value) ° Duct Location (attic, crawl- space, etc.) Duct R -value Cooling Load Btu/hr Cooling Capacity Btu/hr 1. If project is new construction, see Footnotes to Standards Table 151-B and Table 151-C for duct ceiling alternative compliance. 2. ARI Reference Number can be found by entering the equipment model number at http://www. aridirectory. org/ari/ac. php# 3. Listed efficiency on this page must be greater than or equal (>_) to the value shown on the CF -1 R form. 4. When CF -IR is reference it is also applicable to the CF -IR, CF -IR -AA or CF -IR -ALT ALL BOXES MUST BE CHECKED TO BE A VALID FORM § 110-§ 113: HVAC equipment is certified by the California Energy Commission. §150(h): Heating and/or cooling loads calculated in accordance with ASHRAE, SNMCNA, or ACCA. § 150(1): Setback Thermostat on all applicable heating and/or cooling systems meet the requirements of § 112(c). 2008 Residential Compliance Forms August 2009 STATE OF CALIFORNIA SPACE CONDITIONING SYSTEMS, DUCTS AND FANS CEC- CF-6R-MECH-04 Revised 08/09 CALIFORNIA ENERGY COMMISSION INSTALLATION CERTIFICATE CF-6R-MECH-04 Space Conditioning Systems, Ducts and Fans (Page 2 of 4 Site Address: Enforcement Agency: Permit Number: §1500)2: Pipe insulation for cooling system refrigerant suction, chilled water and brine lines meets minimum requirements of Table 150-B and includes a vapor retardant or is enclosed entirely in conditioned space. 2008 Residential Compliance Forms August 2009 STATE OF CALIFORNIA SPACE CONDITIONING SYSTEMS, DUCTS AND FANS Gtu- CF-61i-MEGM-04 Re%nsed 08/09 CALIFORNIA ENERGY COMMISSION INSTALLATION CERTIFICATE CF-6R-MECH-04 Space Conditioning Systems, Ducts and Fans (Page 3 of 4) Site Address: Enforcement Agency: Permit Number: ZO -) I HA'j�izD t�1 . Ducts and Fans § 150(m): Duct and Fans 91 1. All air -distribution system ducts and plenums installed, sealed and insulated to meet the requirements of CMC Sections 601, 602, 603, 604, 605 and Standard 6-5; supply -air and return -air ducts and plenums are insulated to a minimum installed level of R-4.2 or enclosed entirely in conditioned space. Openings shall be sealed with mastic, tape or other duct -closure system that meets the applicable requirements of UL 181, UL 181A, or UL 181B or aerosol sealant that meets the requirements of UL 723. If mastic or tape is used to seal openings greater than 1/4 inch, the co bination of mastic and either mesh or tape shall be used; and 1. Building cavities, support platforms for air handlers, and plenums defined or constructed with materials other than sealed sheet metal, duct board or flexible duct shall not be used for conveying conditioned air. Building cavities and support platforms may contain ducts. Ducts installed in cavities and support platforms shall not be compressed to cause reductions in the cross-sectional area of the ducts. ,E] 2D. Joints and seams of duct systems and their components shall not be sealed with cloth back rubber adhesive duct tapes unless such tape is used in combination with mastic and draw bands. 417. Exhaust fan systems have back draft or automatic dampers. K, 8. Gravity ventilating systems serving conditioned space have either automatic or readily accessible, manually operated dampers. 0�9. Protection of Insulation. Insulation shall be protected from damage, including that due to sunlight, moisture, equipment maintenance, and wind. Cellular foam insulation shall be protected as above or painted with a coating that is water retardant and provides shielding from solar radiation that can cause degradation of the material. A10. Flexible ducts cannot have porous inner cores. DECLARATION STATEMENT • I certify under penalty of perjury, under the laws of the State of California, the information provided on this form is true and correct. • I am eligible under Division 3 of the Business and Professions Code to accept responsibility for construction, or an authorized representative of the person responsible for construction (responsible person). • I certify that the installed features, materials, components, or manufactured devices identified on this certificate (the installation) conforms to all applicable codes and regulations, and the installation is consistent with the plans and specifications approved by the enforcement agency. • I reviewed a copy of the Certificate of Compliance (CF -1R) form approved by the enforcement agency that identifies the specific requirements for the installation. I certify that the requirements detailed on the CF -1R that apply to the installation have been met. • I will ensure that a completed, signed copy of this Installation Certificate shall be posted, or made available with the building permit(s) issued for the building, and made available to the enforcement agency for all applicable inspections. I understand that a signed copy of this Installation Certificate is required to be included with the documentation the builder provides to the building owner at occupancy. Company Name: (Installing Subcontractor or General Contractor or Builder/Owner) vW Responsible Person's N e: Res ible Firson's ature: �i 2008 Residential Compliance Forms August 2009 STATE OF CALIFORNIA SPACE CONDITIONING SYSTEMS, DUCTS AND FANS ,EC- CF -6R -oaten -04 (Kevfsed 08/09) CALIFORNIA ENERGY COMMISSION 7"- - INSTALLATION CERTIFICATE CF-6R-MECH-04 Space Conditioning Systems, Ducts and Fans (Page 4 of 4 Site Address: Enforcement Agency: Permit Number: z d `T ,9 %-) n 'D� CSLB License: Date Signed: Position With Cor o any (Title): 2008 Residential Compliance Forms August 2009 CUPERTINO PURPOSE UTILITY RELEASE REQUEST FORM 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(d)cugertino.orq For residential single family or duplex construction, there are cases where gas and electric utilities are requested to be released prior to the issuance of the certificate of occupancy. Upon approval from the building inspector, the City of Cupertino is allowing both utilities to be released prior to the final sign -off of the building. INSTRUCTIONS 1. Download this form at: htti)://www.cui)ertino.org/index.aspx?paize=297. 2. Complete the form and obtain signatures from both the owner of the property and the primary contractor. 3. Fax, E -Mail, Mail or hand deliver the original signed form to: City of Cupertino Building Division Attn: Utility Release Request Form 408-777-3228 office 10300 Torre Ave. 408-777-3333 fax - Cupertino, CA 95014 building(Z�cuyertino.org 4. Schedule a Gas Meter Release inspection (#403) and/or Electric Meter Release inspection (#404). Please note, a Gas Test inspection (#506) is required prior to or at the same time of the Gas Meter Release inspection. BUILDING INFORMATION (Please complete the following information): APN BLDG PERMIT #: DATE: 3� / SITE ADDRESS: 20131a;f4 a C S_6 tk OWNER'S NAME:PHONE #: a ( FAX #: MAILING DDR SS (if diff�e t fr m site address): l � D CON I I O HONE #: �t^'g q616 FAX #: u U CONTACT: PHONE #: g /' q �� `f' b FAX #: L(;O l I request the City to release my utilities prior to obtaining a final inspection approval for the building. I fully understand the occupants of the building cannot move into the residence until they receive all of the required final sign -offs and the City has issued a certificate of occupancy for the buil 1 Owner:...:..... ... .... Print:........ ................... Date:.. ...: L..... Contractor:................................Print:... /'�.....1.••.•�';•1n►.. /....r,......................Date:..,�•y..� •�/a UtilityReleaseForm_2011.doc revised 08/09/11