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12100114
CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10771 GASCOIGNE DR CONTRACTOR:CH.EN'S CONSTRUCTION PERMIT NO: 12100114 COMPANY OWNER'S NAME:-FANG JEFFREY S 10349 LEOLA CT APT l DATE ISSUED:02/11/2013 OWNER'S PHONE: 4088050616 CUPERTINO,CA 95014 PHONE NO:(408)726-2956 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL El COMMERCIAL License ClassLic. ��C.i-`T r NEW SFDWL 2 STORY 2 134 SF&ATTACHED GARAGE 425 _ Lic. . ✓�r' � SF Contractor 2�i/�1 �, f�/Ziu< �✓ SANITARY IS SUNNYVALE'S JURISDICTION I hereby affirm that I am licensed under the provisions of Chapter (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:$300000 I have and will maintain Worker's Compensation Insurance,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this APN Number:37531024.00 Occupancy Type: permit is.issued. APPLICANT CERTIFICATION I certify that 1 have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct, 1 agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION, indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply Issued lly: Date: with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. --� RE-ROOFS: Signature 1 /�, �, Date f 1 f � r t� All roofs shall be inspected prior to any roofing material being installed.if a roof is �� y1 7 t f installed without first obtaining an inspection,I agree to remove all new materials for inspection. ❑ OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date: the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 1,as owner of the property,or my employees with wages as their sole compensation, will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,Sections 25505,25533,and 25534. I will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations: Health&Safety Code,Section 25532(x)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 1 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 m Owner or authorized agent: �` Dater permit is issued. I certify that in the performance of the work for which this permit is issued,I shall (� not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If,after making this certificate of exemption,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.1 agree to comply with all city and county ordinances and state laws relating to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION indemnify and keep.harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional 9.18. Signature Date CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10771 GASCOIGNE DR CONTRACTOR:CHEN'S CONSTRUCTION PERMIT NO: 12100114 COMPANY OWNER'S NAME: FANG JEFFREY S 10349 LEOLA CT APT I DATE ISSUED:02/1-1/2013 OWNER'S PHONE: 4088050616 CUPERTINO,CA 95014 PHONE NO:(408)726-2956 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL IJ COMMERCIAL License Class Lic.# 6-3 0- � NEW SFDWL 2 STORY 2,134 SF& ATTACHED GARAGE 425 ca/JS�ar vN SF SANITARY IS SUNNYVALE'S JURISDICTION Contractor 'Jar REVISION#I-STRUCTURAL REVISION-ISSUED 7/10/2013 I hereby affirm that easd u I am I' ender the provs o Ch.pter 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:$300000 I have and will maintain Worker's Compensation Insurance,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this APN Number:37531024.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION 1 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 PE 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 FRO C ED 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 I �D granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. RE-ROOFS: Signature Date �7 All roofs shall be inspected prior to any rooting 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 I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date: the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I,as owner of the property,or my employees with wages as their sole compensation, will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,Sections 25505,25533,and 25534. I will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous 1 have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,25533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this ! permit is issued. Owner or authorized agent: .51 Date:-�7 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,I CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address I certify that I have read this application and state that the above information is correct.I agree to comply with all city and county ordinances and state laws relating to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional 9.18. Signature Date CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 .(40,8).777-3228 • FAX (408)777-3333•building(a cugertino.org CUPERTIMO" NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI REVISION DEFERRED ORIGINAL PERMIT PROJECT ADD"SS fD 77 {1 APN H OWNER NAME ` PHONE /r a Q �k7/ E-MAIL STREET ADDRESS. CITY, STATE,ZIP FF CONTACTNAME �l I' PHONE-,Q •. S fG�0 STREET ADDRESS 2,24 f L CITY,STATE,ZIP FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ARCHITECT 13 ENGINEER ❑ DEVELOPER ❑TENANT LICENSENUMBE LI ENSET, E BUS.LIC 9 t, NAME ��l^[ PSI S[(� L- t'c COMPANY NAME E-MAIL FAX �fc,�111; -e.U•c�ek- STREET ADDRESS-�)L2 SSSf ` CITY,STATE,ZIP ',i�� C n PHONE �S '"t Ui ` NAMH LICENSE NUMBER BUS.LIC N COMPANY NAME EMAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONES/0 /0_- /V DESCRIPTION OF WORK J! CJ fXJ'I EXISTING USE PROPOSED USE CONS IL TYPE k STORIES USE TYPE OCC. SQ.FT. VALUATION(S)- EXISTGNEW FLOOR DEMO TOTAL ,AREA AREA AREA NET AREA . BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA .PORCH AREA . DECK AREA TOTAL DECKIPORCH AREA GARAGE AREA: DETACH ❑ATTACH R DWELLING UI,TPS: IS A'SECOND UNrr O YESSECOND STORY []YES BEING ADDED? []NO ADDITION? ONO .PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF. IS THE BLDG AN ❑YES '[(- IVB 'fB� T ON: PLANNING APDL N ❑NO PLANNING APPROVAL EICHLER HOME? l]NO By my signature below,I certify to each of the following: I am the property owner or authorized age 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 build c s ctron. I a orize representatives of Cupertino to enter die above-identified/property for inspection purposes. Signature of Applican Date: J r/ SUPPLEAEENTAL INFORMATT UIRED New SFD or Multifamily dwellings: Apply for demolition permit for existing buildirlg(s):.Demolition permit is required prior to issuance of building permit for new building. _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure form if any Hazardous Materials are being used as part of this project. _Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application. BldgApp_2011.doc I•evised 06/21/11 CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 :is (408)777-3228•FAX(408)777-3333•building(a.cupertino.org CUPERTINO ❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT# PROJECT ADDRESS [ O 1� ( �� i �� D�• APN k OWNER NAME �C� PHONE 8 _ r n/_ E-NIAIL \ STREET ADDRESS CONTACT NAME Ui�em IND PHONE �1�_!'O� / r EMAIL I_�51k0�QYGY�Ir' e�;�d STREET ADDRESS 317,4e2 Vt V CITY,STATE, ZIP AG, tA`f7 G 4*031 FAX ❑ OWNER 11OWNER-BUILDER ❑ OWNER AGENT 11CONTRACTOR 11CONTRACTOR AGENT ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC N COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE ARCHJTECT/ENGINEER NAME , I I ,�I! LICENSE NUMBER C_ 2 �L7,G�/ BUS.LIC d -�4AI COMPANY NAME Vv n Vl EL � � FAX cl�� Pnndtr hsiAb arcln�r�,�der.�o rr STREET ADDRESS :5V 45 CITY,STATE,ZIP 1 t_ ` 51 PHONE'5to 4s-6 A ^� DESCRIPTION OF WORK ,,} 1 EXISTING CSE PROPOSED USE CONSTR.TY �i STORIES !.� USE TYPE OCC' S VALUATION($) AREA QI�C AREA 7,5,NEW 5 DEO ARE SS NOETAREA 6 64 `) B.ATFIROO�-M ,JJ KITCHEN OTHER, REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA. DETACH [ATTACH 4 DWELLING UNITS ISA SECOND UNIT []YES SECOiDSTORV ❑YES BEING ADDED? [3AO ADDITION". _ gi10 PRF-APPLICATION OVIFS IF YES-PROVIDE COPY OF IS THE BLDG AN ❑YES RECEIVED BY: TOTAL VALUATION. PLANNING APPL H ❑.NO PLANNING APPROVAL LETTER EICHLER HOME? [AVO By my signature belove 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 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 uildin ns ti autho representatives of Cupertino to enter the above-identified property for inspection purposes, Signature of Applica Date: /11 - SUPPLEMENTAL INFORMATION PLAN CHECK TYPE ROUTING SLIP New SFD or Multifamily dwellings: Apply for demolition permit for ❑ OVER-THE-COUNTER ❑ BUILDING PLAN REVIEW existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUBLIC WORKS form if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FIRE DEPT Copy of Planning Approval Letter or Meeting with Planning prior to ❑ NLkJOR ❑ SANITARY SEWER DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH BIdgApp_2011.doc revised 06121111 CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 10771 Gascoigne DATE: 10/15/2012 REVIEWED BY: jsg ,UAPN: BP#: �O?/(�(��� °VALUATION: 1$300,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: New Construction PRIMARY SFD or Duplex 2nd Unit? Yes •- No PENTAMATION 1 R3SFDW USE: PERMIT TYPE: WORK New residence 2559 sq ft. SCOPE OCCUPANCY TYPE: TYPE OF FLR AREA PC FEES PC FEE ID BP FEES BP FEE ID CONSTR sJ. R-3 (Custom) II-B,111-B,IV,V-B 2,559 $2,775.16 IR3PLNCK $2,624.29 IR3INSP TOTALS: 2,559 $2,775.16 $2,624.29 Mech. Plan Check Plumb, Plan Check Aiec.Plan C _. :1i_ Permit Pee_ Plumb, Permit Pee: Elec•, Permit Fee Other:llec•h.Insp. E17-- Other Plumb Insp. Other Elec.Insp. Insp. 1 ec. Plumb. hisp. Fee. Elee.Insp. Fee: NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works, Fire,Sanitary Sewer District,School District,etc. . Theseees are based on the prelimina information available and are only an estimate. Contact the De t or addn'1 info. FEE ITEMS(Fee Resolution 11-053 ETf Z/M FEE QTY/FEE MISC ITEMS Plan Check Fee: $2,775.16 Select a Misc Bldg/Structure Suppl. PC Fee: Q Reg. © OT 0.0 1 hrs $0.00 or Element of a Building PME Plan Check: $0.00 Permit Fee: $2,624.29 Suppl. Insp. Fee:Q Reg. O OT 0,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 # Construction Tax: IBCONSTAXR 1 new units $629.29 Adin ittistrative Fee: Q Work Without Permit? Yes 0 No $0.00 Advanced Planning Fee: IPLLONGR $332.67 Select a Non-Residential Trm,el Documentation Fees: Building or Structure i Stronjz Motion Fee: IBSEIS,WCR $30.00 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $12.00 SUBTOTALS: 1 $6,403.41 $0.00 TOTAL FEE: T $6,403.41 Revised: 10/01/2012 CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 10771 GASCOIGNE DR DATE: 05!30!2013 REVIEWED BY: MENDEZ tAPN:: BP#: 1210014 *VALUATION: Iso ;PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex PENTAMATION USE: PERMIT TYPE: t WORK REVISION #1- STRUCTURAL REVISION SCOPE titectr. Plan C.'hrx°kPlumb.Plan ChecFPlan i Ifech. Permit Fee' Plumb.Permit Fee: Flec. Permit Fee. Otlrr r Ira h Insp. Other Plumb Insp. E17-- Other Elec.Insp. ,. i,ee: Plumb. Insp, Fee: Elec.Insp.Fere; E 2LJ NOTE:This estimate does not include fees due to other Departments(ke.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc.). Thesefees are based on the prelimina information available and are only an estimate. Contact the De t or addn7 info. FEE ITEMS (Fee Resolution 11-053 EA.' 711112) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 Select a Misc Bldg/Structure Suppl. PC Fee: (F) Reg. C) OT FO,0 Fhrs $0.00 or Element of a Building PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee.S Reg. Q OT F0,0Thrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Tay ,4dininistrative Fee: 0 Work Without Permit? © Yes Q No $0.00 Advanced Planning,Fee: $0.00 Select a Non-Residential lruvi!Documentation Fees: Building or Structure C) A Strong Motion Fee: $0.00 F1 # Revisions Bldg Stds Commission Fee: $0.00 $799.00 IREVSFDWL SFDWL SUBTOTALS: $0.00 $799.00 TOTAL FEE: $799.00 Revised: 04/29/2013 L INSTALLATION CERTIFICATE (Page 1 of 12) CF-6R Site Address Permit Number LE ��. / r�,� r �/ 2-100 4- Installation certificates(CF-6R)are required for each and every dwelling unit.WhA the installation of measures that require field verification and diagnostic testing is complete,the builder or the builder's subcontractor shall complete diagnostic testing and the procedures specified in this section.When the installation is complete,the builder or the builder's subcontractor shall complete the CF-6R(Installation Certificate),and keep it at the building site for review by the building department.The builder also shall provide a copy of the Installation Certificate to the HERS rater for any measures requiring field verification and diagnostic testing,per Section 10-103(a). WATER HEATING SYSTEMS: Distribution CEC Certified Type If #of Rated Input External Heater MfrName& (Std,Point- Recirculation, Identical (kW or Tank Volume Efficiency Standby Insulation T e Model Number of-Use,etc) Control Type S stems Btu/hr)' alIons (EF,RE)z Loss(%)Z R-value2 t_ 1 For small gas storage(rated input of less than or equal to 75,000 Btufhr),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(RE),Thermal Efficiency,Standby Loss and Rated Input. For instantaneous gas water heaters,list Then-nal Efficiency and Rated Input. 2. R-12 external insulation is mandatory for storage water heaters with an energy factor of less than 0.58. Kitchen Piping: If indicated on the CF-1 R,all hot water piping>3/4 inches in diameter that nuns from the hot water source to the kitchen fixtures is insulated. Faucets&Shower Heads: All faucets and showerheads installed are certified to the Energy Commission,pursuant to Title 24,Part 6,Section 11 1. Central Water Heating in Buildings with Multiple Dwelling Units(required for prescriptive) Lsd"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 V' LN I, the undersigned, verify that equipment listed above my signature is: 1) the actual equipment installed; 2) equivalent to or more efficient than that specified in the certificate of compliance(Form CF-1R)submitted for compliance with the Energy Efficiency Standards for residential buildings; and 3) equipment that meets or exceeds the appropriate requirements for manufactured devices(from the Appliance Efficiency Regulalions or Part 6),where applicable. Installing Subcontractor(Co.Name)OR General Contractor(Co.Name)OR Owner Signature: Date: 1� Copies to:BUILDING DEPARTMENT,HERS RATER(IF APPLICABLE)BUILDING OWNER AT OCCUPANCY Residential Compliance Forms September 2005 INSTALLATION CERTIFICATE (Page 2 of 12) CF-6R Site Address Permit Number G rpt d/ 9-k-(11VO K-4 750142 ' An installation certificate is required to be posted at the building site or made available for all appropriate inspections. (The information provided on this form is required)After completion of final inspection,a copy must be provided to the building department(upon request)and the building owner at occupancy,per Section 10-103(a). FENESTRATION/GLAZING: Manufacturer/Brand Name Total t Quantity of Area Exterior (GROUP LIFE Product U-factor Product SHGC #of Like Product Square Shading Device Comments/Location/ Item RODUCTS) CF-1 R value)2 (SCF-I R value)Z Panes O lionat) Feet or Overhang Special Features 1. AML64CDZ 2. 3. 4, 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. t� Use values from a fenestration product's NFRC label.For fenestration products without an NFRC label,use the default values from Section 116 of the Energy Efficiency Standards. 2) Installed U-factor must be less than or equal to values from CF-1R.Installed SHGC must be less than or equal to values from CF-1R,or a shading device(exterior or overhang)is installed as specified on the CF-IR. Alternatively,installed weighted average U-factors for the total fenestration area are less than or equal to values from CF-JR.If using default table SHG,CC values from§116 identify whether tinted or not. ✓ LJ I, the undersigned, verify that the fenestration/glazing listed above my signature: 1) is the actual fenestration product installed; 2) is equivalent to or has a lower U-factor and lower SHGC than that specified in the certificate of compliance(Form CF-1R) submitted for compliance with the Energy Efficiency Standards for residential buildings; and 3)the product meets or exceeds the appropriate requirements for manufactured devices(from Part 6),where applicable. Item#s Signature Date Installing Subcontractor(Co.Name)OR (if applicable) � /n /� _ General Contractor(Co.Name)OR Owner /I vi✓!�/. ,� � OR Window Distributor Item#s Signature Date Installing Subcontractor(Co.Name)OR (if applicable) General Contractor(Co.Name)OR Owner OR Window Distributor Item#s Signature Date Installing Subcontractor(Co.Name)OR (if applicable) General Contractor(Co.Name)OR Owner OR Window Distributor Copies to: Building Department,HERS Rater(if applicable)Building Owner at Occupancy Residential Compliance Forms April 2005 INSTALLATION CERTIFICATE (Page 3 of 12) CF-6R Site Address Permit Number (077/ C,liS(O l NF X , WC-KrAld M c Sd l 2 001 An installation certificate is required to be posted at the building site or made available for all appropriate inspections. (The information provided on this form is required)After completion of final inspection,a copy must be provided to the building department(upon request)and the building owner at occupancy,per Section 10-103(a). HVAC SYSTEMS: Heating Equipment CEC Certified Mfr. #of Efficiency � Duct Duct or Heating Heating Equip Type Name and Model Identical (AFUE,etc.) Location Piping Load Capacity (pkg.heat um Number Systems >CF-IR value) attic,etc.) R-value Btu/hr (Btu/hr C'Ma�S//tiilGay+ ,'l� AZAA CE C Cooling Equipment CEC Certified Mfr. #of Efficiency � Duct Cooling Cooling Equip Type Name and Model Identical (SEER or EER) Location Duct Load Capacity (pkg.heat um Number Systems >!CF-IR value) attic,etc. R-value Btulbr) (Bm/hr) 1. >symbol reads greater than or equal to what is indicated on the CF-1R value. IInclude both SEER and EER if compliance credit for high EER air conditioner is claimed. v/ Q 1,the undersigned,verify that equipment listed above is: 1) is the actual equipment installed,2)equivalent to or more efficient than that specified in the certificate of compliance (Form CF-1R) submitted for compliance with the Energy Efficiency Standards for residential buildings, and 3) equipment that meets or exceeds the appropriate requirements for manufactured devices(from the Appliance Efficiency Regulations or Part 6),where applicable. Installing Subcontractor(Co.Name)OR General Contractor(Co.Name)OR Owner Signature: Date: -) .aV i Copies to:BUILDING DEPARTMENT,HERS RATER(IF APP LICA LE)BUILDING OWNER AT OCCUPANCY Residential Compliance Forms April 2005 INSTALLATION CERTIFICATE (Page 4 of 12) CF-6R Site Address Permit Number 7-7 S C.d N`E W rug' 012_10011k INSTALLER COMPLIANCE STATEMENT FOR DUCT LEAKAGE INSTALLER COMPLIANCE STATEMENT The building was: ✓ Mested at Final ✓ El"'Tested at Rough-in INSTALLER VISUAL INSPECTION AT FINAL CONSTRUCTION STAGE FOR NEW DUCTS: EJ Remove at least one supply and one return register,and verify that the spaces between the register boot and the interior finishing wall are properly sealed. l� If the house rough-in duct leakage test was conducted without an air handler installed,inspect the connection points between the ?ir handler and the supply and return plenums to verify that the connection points are properly sealed. IR Inspect all joints to ensure that no cloth backed rubber adhesive duct tape is used on new ducts. ✓ ❑ DUCT LEAKAGE REDUCTION Procedures or field verification and diagnostic testing of air distribution systems are available in RA CM,Appendix RC4.3 NEW CONSTRUCTION: Duct Pressurization Test Results(CFM @ 25 Pa) Measured Values 1 Enter Tested Leakage Flow in CFM: Fan Flow: Calculated(Nominal: ✓ ❑ Cooling✓ ❑Heating)or✓ ❑Measured 2 If Fan:Flow is Calculated as 400 cfm/ton x number of tons or as 21.7 cfm/(kBtu/hr)x Heating ✓ ✓ Capacity in Thousands of Btu/hr,enter total calculated or measured fan flow in CFM here: Pass if Leakage Percentage< 6%for Final or<4%at Rough-in without air handle: 3 ❑ Pass 11 Fail 100 x Line# 1 / Line#2 ALTERATIONS:Duct System and/or HVAC Equipment Change-Out Enter Tested Leakage Flow in CFM from Pre-Test of Existing Duct System Prior to Duct 4 System Alteration and/or Equipment Change-Out. Enter Tested Leakage Flow in CFM from Final Test of New Duct System or Altered Duct 5 System for Duct System Alteration and/or Equipment Chan e-Out. Enter Reduction in Leakage for Altered Duct System w 6 (Line#4 Minus Line#5 — (Only if Applicable) 7 Enter Tested Leakage Flow in CFM to Outside(Only if Applicable) ✓ ✓ Entire New Duct System-Pass if Leakage Percentage <6%for Final. ❑ Pass ❑ Fail 8 100 x Line#5 / Line#2)11 TEST OR VERIFICATION STANDARDS: For Altered Duct System and/or HVAC Equipment Change- ✓ ✓ Out Use one of the following four Test or Verification Standards for compliance: 9 Pass if Leakage Percentage< 15% [100 x [ (Line#5)/ (Line#2)]] ❑ Pass ❑ Fail 10 Pass if Leakage to Outside Percentage< 10%[100 x [(Line#7)/ (Line#2)]] ❑ Pass ❑ Fail Pass if Leakage Reduction Percentage>60% [100 x [ (Line#6)/ (Line#4)]] ❑ Pass 11 Fail 11 and Verification by Smoke Test and Visual Inspection 12 Pass if ealing of all Accessible Leaks and Verification by Smoke Test and Visual Ins ection ❑ Pass ❑ Fail Pass if One of Lines#9 through#12 pass ❑ Pass ❑ Fail ✓ ,the undersigned,verify that the above diagnostic test results were performed in conformance with the requirements for compliance credit.I,the undersigned,also certify that the newly installed or retrofit Air-Distribution System Ducts,Plenums and Fans comply with Mandatory requirements specified in Section 150(m)of the 2005 Building Energy Efficiency standards. Installing Subcontractor(Co.Name)OR General Contractor(Co.Name)OR Owner Signature: �. Date: •� -2 (� Copies to:BUILDING DEPARTMENT,HERS RATER(IF APPLICABLE)BUILDING OWNER AT OCCUPANCY Residential Compliance Forms December 2005 INSTALLATION CERTIFICATE (Page 5 of 12) CF-6R Site Address q{;�1 Permit Number 677 C�,, r4)L) C �7UI 121 GOI1 ✓ ❑ THERMOSTATIC EXPANSION VALVE(TXV) Procedures for field verif talion of thermostatic expansion valves are available in RACM,Appendix RI. ✓ ✓ Access is provided for inspection. The procedure shall �, consist of visual verification that the TXV is installed on ✓ WX es ❑No the system and installation of the specific equipment El shall be verified. L= Yes is a gass I ILIU—s I Fail ✓❑ REFRIGERANT CHARGE MEASUREMENT Verification for Required Refrigerant Charge and Adequate Airflow for Split System Space Cooling Systems without Thermostatic Expansion Valves Outdoor Unit Serial# 47 Location Outdoor Unit Make Outdoor Unit Model 3 Cooling Capacity Btu/hr Date of Verification Date of Refrigerant Gauge Calibration (must be checked monthly) Date of Thermocouple Calibration (must be checked monthly) Standard Charge Measurement Procedure (outdoor air dry-bulb 55°F and above): Procedures for Determining Refrigerant Charge using the Standard Method are available in RACM,Appendix RD2. Note:The system should be installed and charged in accordance with the manufacturer's specifications before starting this procedure. Measured Temperatures Supply(evaporator leaving)air dry-bulb temperature(Tsupply,db) OF Return(evaporator entering) air dry-bulb temperature(Tretorn,db) OF Return(evaporator entering)air wet-bulb temperature(Treturn,wb) OF Evaporator saturation temperature(Tevaporator,sat) OF Suction line temperature(Tsuction,db) OF Condenser(entering)air dry-bulb temperature(Tcondenser,db) OF Su erheat Charge Method Calculations for Refrigerant Charge Actual Superheat =Tsuction,db—Tevaporator,sat �F Target Superheat(from Table RD-2) OF Actual Superheat—Target Superheat (System passes if between-5 and+5°F) °F Temperature Split Method Calculations for Adequate Airflow S lit Method Calculation is not necessary i Ade uate Air ow credit is taken Actual Temperature Split =T return,db Tsupply,db OF Target Temperature Split(from Table RD3) OF Actual Temperature Split Target Temperature Split (System passes if between- OF 3°F and+3°F or,upon remeasurement,if between -3°F and-100°F Residential Compliance Forms April 2005 INSTALLATION CERTIFICATE (Page 6 of 12) CF-6R Site Address Permit Number i 771 Ole, (:yR6-T11vv 44 %Z N- Standard Charge Measurement Summary: System shall pass both refrigerant charge and adequate airflow calculation criteria from the same measurements.If corrective actions were taken,both criteria must be remeasured and recalculated. ✓ es O No I System Passes Alternate Charge Measurement Procedure (outdoor air dry-bulb below 55°F) Note: The system should be installed and charged in accordance with the manufacturer's specifications and installer verification shall be documented on CF-6R before starting this procedure. If outdoor air dry-bulb is 55 OF or above,installer shall use the Standard Charge Measure Procedure: Procedures for Determining Refrigerant Charge using the Alternate Method are available in RACM,Appendix RD3. Weigh-lin Charging Method for Refrigerant Charge Actual liquid line length: ft Manufacturer's Standard liquid line length: ft Difference(Actual—Standard): ft Manufacturer's correction(ounces per foot) x difference in length = ounces (+=add)(-=remove) Measured Airflow Method for Adequate Airflow Verification available in RACM,Appendix RD2.6 Calculated Airflow: Cooling Capacity(Btu/hr) X 0.033 (cfm/Btu-hr)= CFM Measured Airflow is CFM(Measured airflow must be greater than the calculated airflow). Alternate Charge Measurement Summary: System shall pass both refrigerant charge and adequate airflow calculation criteria from the same measurements. If corrective actions were taken,both criteria must be remeasured and recalculated. ✓ Yes O No I System Passes Installing Subcontractor(Co.Name)OR General Contractor(Co.Name)OR Owner Signature: Date: -2 Copies to:BUILDING DEPARTMENT,HERS RATER(IF APPLIC BLE)BUILDING OWNER AT OCCUPANCY Residential Compliance Forms April 2005 INSTALLATION CERTIFICATE (Page 7 of 12) CF-6R Site Address Permit Number 1077 / C U 1 A, C4 J `.1'Uf 2 MISCELLANEOUS CREDITS ✓ UDIAGNOSTIC SUPPLY DUCT LOCATION,SURFACE AREA AND R-VALUE Procedures for field verification and diagnostic testing for this group compliance credits are available in RACM,Appendix RC, RE&RH. ✓ EF-L.ESS THAN 12 LINEAL FEET OF SUPPLY DUCT OUTSIDE OF CONDITIONED SPACE CO>4PLIANCE CREDIT L�t ❑No Less than 12 lineal feet of supply duct outside of conditioned space. Yes to this compliance credit is a pass ✓ B Pass ✓ ❑Fail ✓ ffSUPPLY DUCTS LOCATED IN CONDITIONED SPACE COMPLIANCE CREDIT ✓ es ❑No I Ducts are located within the conditioned volume of building. Yes to this compliance credit is a pass ✓ 04ass ✓ ❑ Fail Duct System Design verification is required for a compliance credit for the following: 1. Supply duct surface area reduction 2. Buried supply ducts on the ceiling 3. Deeply buried supply ducts ✓ ❑ DUCT SYSTEM DESIGN VERIFICATION ✓ Yes ❑No I Adequate airflow verified ✓ 0Yes ❑No The duct system design plan meets the requirements specified in RACM,Appendix RE,Section RE.4.2 ✓ Yes ❑No The duct system design plan exists on building plans ✓ D' es ❑No Duct sizes,duct system layout and locations of supply&return registers match the duct system design plan Yes to all is a pass ✓ ass ✓ ❑Fail ✓ ❑ SUPPLY DUCTS SURFACE AREA REDUCTION COMPLIANCE CREDIT R-4.2 R-6.0 R-8.0 Crawl Deeply Duct Surface Surface Surface Attic Space Basement Covered Covered Other Diameter Area Area Area ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Total Surface Area for Each R-Value= ✓ ❑ Yes 1 ❑ No tches Performance's CF-1R? ✓ ✓ Yes to all is a ass Cl Pass Cl Fail ✓ ElBURIED DUCTS ON THE CEILING COMPLIANCE CREDIT Yes ❑No Buried Ducts on the Ceiling Q/Yes ❑No Verified High Insulation Installation Quality ✓ ✓ Yes to ducts stem design,supply duct surface area reduction and this compliance credit is a ass Pass ❑Fail ✓ ❑DEEPLY BURIED DUCTS COMPLIANCE CREDIT 13'.Yes ❑No Deeply Buried Ducts 151Yes ❑No Verified High Insulation Installation Quality ✓ ✓ Yes to ducts stem desi ,supply duct surface area reduction and this compliance credit is a ass I QF�ass ❑Fail Copies to:BUILDING DEPARTMENT,HERS RATER(IF APPLICABLE)BUILDING OWNER AT OCCUPANCY Residential Compliance Forms April 2005 INSTALLATION CERTIFICATE (Page 8 of 12) CF-6R Site Address Permit Number 077 GSC v6iV;; ry, Ill ZInno 1/13 FAN WATT DRAW Proceduresor measuringthe air handler wall draw are available in RA CM, A endix RE3.2. ✓Method For Fan Watt Draw Measurement ❑ RE3.2.1 Portable Watt Meter Measurement ❑ RE3.2.2 Utility Revenue Meter Measurement Measured Fan Watt Draw Watts Measured Fan Flow enter total cfm from airflow verification cfm Enter results of Watts/cfm Watts/cfm ✓ L,Yes ❑No Measured fan watt/cfm draw is equal to or lower than the fan watt/cfm draw documented in CF-1 R ❑ Yes is a pass Pass Fail ✓ ❑ ADEQUATE AIRFLOW VERIFICATION Procedures for measuring the airflow are available in RA CM,Appendix RE3.1. ✓Method For Airflow Measurement ❑ RE4.1.1 Dia nostic Fan Flow Using Flow Capture Hood ❑ RE4.1.2 Diagnostic Fan Flow Using Plenum Pressure Matching ❑ RE4.1.3 Dia nostic Fan Flow Using Flow Grid Measurement des ❑No Duct design exists on plans Measured Airflow: Total cfm Rated Tons cfm/ton cfm/ton ✓ AG Yes ❑No Measured airflow is greater than the criteria in Table RE-2 ✓ ✓ Yes is a pass Pass Fail ✓ ❑ MAXIMUM COOLING CAPACITY Procedures for del rmining maximum cooling load capacity are available in RA CM,Appendix RF3. 1 ✓ Yes ❑No Adequate airflow verified(see adequate airflow credit) 2 ✓ C/Yes ❑No Refrigerant charge or TXV 3 ✓ LY�es ❑No Duct leakage reduction credit verified 4 ✓ O/Yes ❑No Cooling capacities of installed systems are<_to maximum cooling capacity indicated on the Performance's CF-1R and RF-3. ' / If the cooling capacities of installed systems are>than maximum V/ V/5 V/ LYYes ❑No cooling capacity in the CF-1R,then the electrical input for the installed systems must be<_to electrical input in the CF-1R. ❑ Yes to 1,2,and 3;and Yes to either 4 or 5 is a pass Pass Fail ✓❑ HIGH EER AIR CONDITIONER Procedures foVver*ication are available in RA CM,Appendix RI. 1 v/ Yes ❑No I EER values of installed systems match the CF-1R 2 ✓ Eftes ❑No Fors lits stem,indoor coil is matched to outdoor coil ✓ Y, ✓ 3 ✓ es ❑No Time Delay Relay Verified(If Required) ❑ Yes to 1 and 2;and 3 If Required)is a pass Pass Fail Installing Subcontractor(Co.Name)OR General Contractor(Co.Name)OR Owner Signature: Z / ,A_� Date: (� Copies to:BUIL DIN DEPARTMENT,HERS RATER(IF APPLICABLE)BUILDING OWNER AT OCCUPANCY Residential Compliance Forms April 2005 INSTALLATION CERTIFICATE (Page 9 of 12) CF-6R Site Address Permit Number -2-7 A-5"1 -- Ok C�v d SSV 2 oo1 An installation certificate is required to be posted at the building site or made available for all appropriate inspections. (The information provided on this form is required)After completion of final inspection,a copy must be provided to the building department(upon request)and the building owner at occupancy,per Section 10-103(a). BUILDING ENVELOPE LEAKAGE DIAGNOSTICS ✓ D ENVELOPE SEALING INFILTRATION REDUCTION Procedures for field verification and diagnostic testing of envelope leakage are available in RA CM,Appendix RC. Diagnostic Testing Results ✓ ✓ Building Envelope Leakage(CFM @ 50 Pa)as measured by Rater: 1Ef ❑ Measured envelope leakage less than or equal to the required level from Yes No CF-1R? 2. ❑ Is Mechanical Ventilation shown as required on the CF-IR? Yes No 2a D ❑ If Mechanical Ventilation is required on the CF-1R(`Yes' in line 2),has it Yes No been installed? Check this box `yes' if mechanical ventilation is required(`Yes' in line 2) 2b. ❑ and ventilation fan watts are no greater than shown on CF-1R. Yes No Measured Watts= Check this box"yes"if measured building infiltration(CFM @ 50 Pa) is 3. ElCheck than the CFM @ 50 values shown for an SLA of 1.5 on CF-1R Yes No If this box is checked no mechanical ventilation is required,) Check this box"yes"if measured building infiltration(CFM @ 50 Pa) is 4 [ ❑ less than the CFM @ 50 values shown for an SLA of 1.5 on CF-1R, Yes No mechanical ventilation is installed and house pressure is greater than minus 5 Pascal with all exhaust fans operating. Pass if: a.Yes in line 1 and line 3,or ✓ ✓ b. Yes in line 1 and line2,2a,and 2b,or c. Yes in line I and Yes in line 4. ❑' ❑ �-,� Otherwise fail. Pass Fail v/ Lyl,the undersigned,verify that the building envelope leakage meets the requirements claimed for building leakage reduction below default assumptions as used for compliance on the CF-1R. This is to certify that the above diagnostic test results and the work I performed associated with the test(s)is in conformance with the requirements for compliance credit. (The builder shall provide the HERS provider a copy of the CF-6R signed by the builder employees or subcontractors certifying that diagnostic testing and installation meet the requirements for compliance credit.) Test Performed Installing Subcontractor(Co.Name)OR General Contractor(Co.Name)OR Owner Signature: Date: Copies to:BUILDING DEPARTMENT,RERS RATER(IF APPLICABLE), BUILDING OWNER AT OCCUPANCY Residential Compliance Forms April 2005 INSTALLATION CERTIFICATE (Page 10 of 12) CF-6R Site Address Permit Number Insulation Installation Quality Certificate ✓ Eg'Description of Insulation,(CF-6R, formerly IC-1)signed by the installer stating: insulation manufacturer's name, material identification,installed R-values,and for loose-fill insulation: minimum weight per square foot and minimum inches ✓ Il,,��lnstallation meets all applicable requirements as specified in the High Quality Insulation Installation Procedures (ACM,Appendix RH) ✓ F OOR or ❑ ❑ All floor joist cavity insulation installed to uniformly fit the cavity side-to-side and end-to-end Yes No NA CD/ ❑ ❑ Insulation in contact with the subfloor or rim joists insulated Yes No NA ❑ ❑ Insulation properly supported to avoid gaps,voids,and compression Yes No NA ✓ WALLS ❑ ❑ Wall stud cavities caulked or foamed to provide an air tight envelope Yes No NA ❑ ❑ Wall stud cavity insulation uniformly fills the cavity side-to-side, top-to-bottom,and front-to-back Yes No NA Gy ❑ ❑ No gaps Yes No NA ❑ ❑ No voids over 3/4"deep or more than 10%of the batt surface area. Yes No NA ❑ ❑ Hard to access wall stud cavities such as;corner channels,wall intersections,and behind Yes No NA tub/shower enclosures insulated to proper R-Value Nr ❑ ❑ Small spaces filled Yes No NA ❑ ❑ Yes No NA Rim-joists insulated ❑ ❑ Loose fill wall insulation meets or exceeds manufacturer's minimum weight-per-square-foot Yes No I NA I requirement ✓ OOF/CEILING PREPARATION ❑ ❑ All draft stops in place to form a continuous ceiling and wall air barrier Yes No NA ❑ ❑ All drops covered with hard covers Yes No NA ❑ ❑ All draft stops and hard covers caulked or foamed to provide an air tight envelope Yes No NA ❑ ❑ All recessed light fixtures IC and air tight(AT)rated and sealed with a gasket or caulk between the Yes No NA housing and the ceiling Q/ ❑ ❑ Floor cavities on multiple-story buildings have air tight draft stops to all adjoining attics Yes No NA ❑ ❑ Eave vents prepared for blown insulation-maintain net free-ventilation area Yes No NA 57- ❑ ❑ Knee walls insulated or prepared for blown insulation Yes No NA ❑ ❑ Area under equipment platforms and cat-walks insulated or accessible for blown insulation Yes No NA Yes No NA Attic rulers installed Residential Compliance Forms INSTALLATION CERTIFICATE (Page 11 of 12) CF-6R Site Address Permit Number 10771 XC 0 A6- 40 t: `��Ll 6' ✓ ROOF/CEILING BATTS COY ❑ ❑ Yes No NA No gaps Yes No NA No voids over 1/4 in.deep or more than 10%of the batt surface area. ❑ ❑ Ye No I NA Insulation in contact with the air-barrier ❑ ❑ Yes No NA Recessed light fixtures covered ❑ ❑ Net free-ventilation area maintained at eave vents Yes No NA ✓ OOF/CEILING LOOSE-FILL Y6s No NA Insulation uniformly covers the entire ceiling(or roof)area from the outside of all exterior walls. YNo NA Baffles installed at eaves vents or soffit vents-maintain net free-ventilation area of eave vent Yes ❑ ❑ Yes No NA Attic access insulated ❑ ❑ Yes No NA Recessed light fixtures covered ❑ ❑ Yes No NA Insulation at proper depth—insulation rulers visible and indicating proper depth and R-value 7 ❑ ❑ Loose-fill insulation meets or exceeds manufacturer's minimum weight and thickness requirements Yes No NA for the target R-value. Target R-value . Manufacturer's minimum required weight for the target R-value (pounds-per-square-foot). Manufacturer's minimum required thickness at time of installation . Manufacturer's minimum required settled thickness .Note: To receive compliance credit the HERS rater shall verify that the manufacturer's minimum weight and thickness has been achieved for the target R-value. CF-61?only) DECLARATION ✓ El"'I hereby certify that the installation meets all applicable requirements as specified in the Insulation Installation Procedures. Installing Subcontractor(Co.Name)OR General Contractor(Co.Name)OR Owner Signature: Date: Copies to:BUILDING DEPARTMENT,HERS RATER(IF APPLICABLE), BUILDING OWNER AT OCCUPANCY Residential Compliance Forms April 2005 INSTALLATION CERTIFICATE (Page 12 of 12) CF-6R Site Address Permit Number 0791 C K-11 U) L-4 l 12-100l County Subdivision Lot Number Description of Insulation (Formerly IC-1 Form) 1. RAISED FLOOR Material JBrand Name Thickness (inches) 3 Thermal Resistance (R-Value) 2. SLAB FLOOR/PERIMETER Material Brand Name Thickness (inches) Thermal Resistance (R-Value) Perimeter Insulation Depth (inches) 3. EXTERIOR WALL Frame Type A. Cavity Insulation. Material SS Brand Name Thickness(inches) v Thermal Resistance(R-Value) 3 B . Exterior Foam Sheathing Material Brand Name Thickness (inches) Thermal Resistance (R-Value) 4. FOUNDATION WALL Material (n1MP Brand Name Thickness (inches) Thermal Resistance(R-Value) 3 5. CEILING Batt or Blanket Type Brand Name Thickness (inches) Thermal Resistance(R-Value) 30 Loose Fill Type Brand Contractor's min installed weight/ft' lb Minimum thickness inches Manufacturer's installed weight per square foot to achieve Thermal Resistance(R-Value) 6. ROOF Material Brand Name Thickness (inches) Thermal Resistance(R-Value) 3O Declla ation ✓ LJ I hereby certify that the above insulation was installed in the building at the above location in conformance with the current Energy Efficiency Standards for residential buildings(Title 24,Part 6,California Code of Regulations)as indicated on the Certificate of Compliance,where applicable. Item#s Signature Date Installing Subcontractor(Co.Name)OR (if applicable) General Contractor(Co.Name)OR Owner OR Window Distributor Item#s Signature Date Installing Subcontractor(Co.Name)OR (if applicable) General Contractor(Co.Name)OR Owner OR Window Distributor Item#s Signature Date Installing Subcontractor(Co.Name)OR (if applicable) General Contractor(Co.Name)OR Owner OR Window Distributor Residential Compliance Forms April 2005 L 1�10 0 ( 1 � CALGREEN SIGNATURE DECLARATIONS Project Name: 10771 Gascoigne Dr, Cupertino, CA Project Address: 10771 Gascoigne Dr, Cupertino, CA Project Description: To build a 2,559 sf new house. SECTION 1 — DESIGN VERIFICATION Complete all lines of Section 1 —"Design Verification"and submit the completed checklist(Columns 1 and 2)with the plans and building permit application to the Building Department. The owner and design professional responsible for compliance with CalGreen Standards have revised the plans and certify that the items checked above are hereby incorporated into the project plans and will be implemented into the project in accordance with the requirements set forth in the 2010 California Green Building Standards Code as adopted by the City of Cupertino. 10/10/2012 Owner's Signature Date Owner's Name (Please Print) 10/10/2012 Design Professional's Signature Date Huiwen Hsiao Design Professional's Name (Please Print) 10/10/2012 Signature of License Professional responsible for CalGreen compliance Date Huiwen Hsiao Name of License Professional responsible for CalGreen compliance(Please Print) Phone hhsiao O archirender.com Email Address for License Professional responsible for CalGreen compliance SECTION 2 — IMPLEMENTATION VERIFICATION Complete, sign and submit the competed checklist,including column 3,together with all original signatures on Section 2 to the Building Department prior to Building Department final inspection. I have inspected the work and have received sufficient documentation to verify and certify that the project identified above was constructed in accordance with thi Gree tylding C list and in accordance with the requirements of the 2010 California Green Building Standards d s ado t y t e ' of Cupertino. _ 02/20/2014 Signature of License Professional respo a for a reen compliance Date Huiwen Hsiao Name of License Professional responsible for CalGreen compliance(Please Print) Phone hhsiao@archirender.com Email Address for License Professional responsible for CalGreen compliance Page 5 of 5 CalGreen_2010.doc revised 08/27/11