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05-4922 (MECH)T. \,', a P.O. BOX 1504 78-495 CALLE TAMPICO LA QUINTA; CALIFORNIA 92253 Application Number: 1 05-00004922 Property Address: 56205 RIVIERA APN: 762-021-022- - - Application description: MECHANICAL Property Zoning: LOW DENSITY RESIDENTIAL Application valuation: 5196 Applicant: Architect or Engineer: LICENSED CONTRACTOR'S DECLARATION BUILDING & SAFETY DEPARTMENT BUILDING PERMIT I hereby affirm under penalty of perjury that 1 am licensed under provisions of Chapter 9 (commencing with Section 7000) ision 3 of the Business and Professionals Code, and my License is in full force and effect. License Cla_/. License No.: 374937 Date: ry Contractor: I v OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury that I am exempt from the Contractor's State License Law for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county that requires a permit to construct, alter,- improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractor's State License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).: (_) 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 and Professions Code: The Contractors'.State License Law does not apply to an owner of property who builds or improves thereon, and who does the work himself or herself through his or her own employees, provided that the improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for the purpose of sale.). 1 _) I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of property who builds or improves thereon, and who contracts for the projects with a contractor(s) licensed pursuant to the Contractors' State License Law.). (_ 1 I am exempt under Sec. , B.&P.C. for this reason Date: Owner: CONSTRUCTION LENDING AGENCY I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ�C.). Lender's Name: Lender's Address: LQPERMIT Owner: JANICE GOTTLIEB 56205 RIVIERA' LA QUINTA, CA 92253 -VOICE (760) 777-7012 FAX (760) 777-7011 INSPECTIONS (760) 777-7153 Date: 11/04/05 NOV o 4- 2005 IDI. Contractor: C't O PALM DESERT AIR CONDITIONING QN-41V i 42081 BEACON HILL PALM DESERT, CA 92211 (760)346-0677. Lic. No.: 374937 -----------------------------_----------------- WORKER'S COMPENSATION DECLARATION hereby affirm under penalty of perjury one of the following declarations: I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. _ I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy number are: Carrier STATE FUND Policy Number 1795546 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 workers' compensation laws of California, and agree that, if I should become subject to the workers' compensation provisions of Section forthwith comply with those provisions. Dated A V, W Applicant: WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. APPLICANT ACKNOWLEDGEMENT IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the conditions and restrictions set forth on this application. 1. Each person upon whose behalf this application is made, each person at whose request and for . whose benefit work is performed under or pursuant to any permit issued as a result of this application, the owner, and the applicant, each agrees to, and shall defend, indemnify and hold harmless the City of La Quinta, its officers, agents and employees for any act or omission related to the work being performed under or following issuance of this permit. 2. Any permit issued as a result of this application becomes null and void if work is not commenced within 180 days from date of issuance of such permit, or cessation of work for 180 days will subject permit to cancellation. . 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 cou t o enter upon the above-mentioned property for inspection purposes. Date:/•/ � Signature (Applicant or Agent): Application Number �. 05-00004922 ' Permit . . MECHANICAL Additional desc . Permit Fee . . . . 35.00 Plan Check Fee 3.75 Issue -Date . . . Valuation . . 0 Expiration Date 5/03/06 Qty Unit Charge Per Extension BASE FEE 15.00 1.00 11.0000 EA • MECri P-UKNAcE >lUUK 11.00 1.00 9.0000 EA MECH APPL REP/ALT/ADD 9.00 Special Special Notes and Comments -------------------------- - ---------------- NEW 2.5 TON HEAT PUMP UNIT FOR CASITA Fee summary Charged Paid. - Credited Due Permit Fee Total 35.00 .00 .00 35.00 Plan Check Total 3.75 .60 .00 3.75 Grand Total 38.75 .00 .00 38.75 LQPERMIT r Bin # City of La Quinta Building & Safety Division Permit #� A P.O. Box 1504, 78-495 Calle Tampico La Quinta, CA 92253 - (760) 777-7012 Building Permit Application and Tracking Sheet Project Address: / ' `t+Q-�► Owner's Name: '�py� C, L C,I.1. �j�b A. P. Number: Address: C4p •ZoS i4 rL� Legal Description: City, ST, Zip: (2A 011224 Contractor '4Q'L.'` 4ix C4, -p C6 .Telephone: - M -.'I �•��* - o Address: 4'L-0 Project Description: City, ST, Zip: 4 'LZ N [�t� Telephone: 406 , : (p •C)G?7 glob State Lic. # : 3-7q q3-7 (,W City Lic. #: Arch., Engr., Designer. Address: City, ST, Zip: Telephone: Construction Type: Occupancy: State Lic. #: _ Project type (circle one): New Add'n Alter Repair Demo Name of Contact Person: Sq. Ft:: #Stories: #Units: Telephone # of Contact Person: Estimated Value of Project: APPLICANT: DO NOT WRITE BELOW THIS LINE # Submittal Req'd Recd TRACKING PERMIT FEES Plan Sets Plan Check submitted Item Amount Structural Calcs. ------------ Reviewed, ready fol• corrections Plan Check Deposit . Plan Check B alance Truss Calcs. Called Contact Person Energy Cates. Plans picked up Construction Flood plain plan Plans resubmitted Mechanical Grading plan 2"u Review, ready for corrections/issue Electrical Subcontactor List Called Contact Person Plumbing S.M.I. Grant Deed Plans picked up H.O.A. Approval Plans resubmitted Grading Developer Im pact Fee A.I.P.P. IN HOUSE:- '"' Review, ready for corrections/issue Planning Approval Called Contact Person Pub. Wks. Appr Date of permit issue School Fees Total Permit Fees 4 PALM DESERT AIR CONDITIONING ' & HEATING CO. uc. e37asa� . "Where Quality Counts Since 1979!" 42-081 BEACON HILL • PALM DESERT, CA 92211 T: (760) 346-0677 • F: (760) 346-5200 E: INFO@PALMDESERTAC,COM Job Address JANICE GOTTLIEB 56-205 RIVIERA LA QUINTA, CA 92253 (760) 771-5611 JOB ORDER JOB NO.: 1069 NO: OF DAYS: 1 SALES DATE: 10/31/2005 INSTALLATION DATE: 11/04/2005 Job Notes COMFORT ADVISOR: I ROBERT POWELL LEAD: EED TO PERFORM PRE & POST TEST CITY OF LA QUINTA BUILDING & SAFETY DEPT. APPROVED FOR CONSTRUCTION DATE Icy BY c Quantity . Manufacturer Tons) SEER EER HSPF AFUE ARI # Loca Ref. Conf. tion 1 AMANA 2.0 12.00 11.00 07.2 1 1 1,11-22 1 SAC I GROUND TXV: 0 Factory Installed El Field Installed Part No. Filter Size filter Type ESF Thermostat Manufacturer & Model 1WHITE ROGERS 1 F80-261 Model / Serial Numbers Tasks System 1 11 . Task Model Number Serial Number GENREPLACE ARUF030 . 1 0510172346 GENREPLACE RHE30C2 0403638761 PERMIT DUCT TEST NONE @ FOR AUTHORIZED PALM DESERT AIR Package Qty Parts Com. H.E. Investment DELUXE 1 5 10 0 $3,468.00 DELUXE 1 5 0 20 $2,728.00 1 $100.00 1 $100.00 JOB SUB -TOTAL: $6,396.00 UTILITY REBATE: $0.00 MANUFACTURER REBATE: $0.00 OT.HERt $1,200.00, TOTAL INVESTMENT:1 $5,196.00 DEPOSIT: $0.00 AMOUNT DUE UPON COMPLETION: $5,196.00 AMOUNT FINANCED: $0.00 I CONDITIONING & HEATING COMPANY CERTIFICATE OF COMPLIANCE: RESIDENTIAL (Page 1 of 5) CF -1R Project Title DateButldingsPermrt'#i Location Comments ' (attic, garage, ical, etc. 'fi%Sj+�( ggY'S.rf}M'W y Z.» s'4Y'-4p 3 "Plan Check / Dates .' Documentation Author Telephone te;�Rc" Compliance Method (Prescriptive) Climate Z e €Eh rcement A' enc :Use , ✓ B Alternative Component Package Method: (check one) C D D (Alternative) Package C and Package D choices require HERS rater field verification and/or diagnostic testing (see CF -1R page 3) For Package D Alternative 'see Appendix B' Table 151-C Footnotes 7-14 GENERAL INFORMATION LL Total Conditioned Floor Area (CFA) ft, ' Average Ceiling Height: ft u Maximum Allowed West Facing Fenestration Products Per Table 151-B or 151-C ---- (5% X CFA) ft, Maximum Allowed Total Fenestration Products Per Table 151-B or 151-C ----(20% X CFA) ftZ ✓ WBuilding Type: (check one or more)_ Single Family Multifamily Addition Alteration (If adding fenestration fill out WS -4R, Fenestration Maximum Allowed Area Worksheet and see' Section 8.3.2 for Additions and 8.3.3 for Alterations.) Number of Stories: Number of Dwelling Units: Floor Construction Type: Slab/Raised Floor (circle one or both) Front Orientation: North'/ South / East / West / All Orientations (input front orientation in degrees from True North and circle one). ✓ 0 RADIANT BARRIER (required in climate zones 2, 4, 8-15) ` OPAQUE SURFACES INCLUDING OPAQUE DOORS Component Type (Wall, Frame Roof, Floor, Type Cavity .Slab Edge, (Wood or Insulation Doors) Metal R -Value Assembly U - factor (for wood, Continuous metal frame and Insulation mass R -Value assemblies) Joint Appendix • IV Reference , Roof Radiant Barrier Installed Yes or No Location Comments ' (attic, garage, ical, etc. 1 occ Juwu\ rnppuiiuix i v ut aecuun i v.t,, 1 v ..S ano 1 v.4, wmcn is the oasis rontne U -tactor criterion. U -tactors can not exceed prescriptive value to show equivalence to R -values. ' Residential Compliance Forms April 2005 CERTIFICATE OF COMPLIANCE: RESIDENTIAL (Page 2 of 5) CF -1R Project Title Qn \("- �l if' . O Date / FENESTRATION PRODUCTS – U -FACTOR AND SHGC ✓ ❑ FENESTRATION MAXIMUM ALLOWED AREA WORKSHEET WS -411 –must be included for New Construction, Additions and Alterations. Fenestration #/Type/Pos. (Front, Left, Rear, Right, Skylight) Orien- ' tation, N, S, E, Wt Area U -factor ft2 U-factor2 Source Exterior Shading/Overhangs6 7 SHGC ✓ box if WS -3R is SHGC4 Sources included ❑. - ❑ 13 ❑ 1) Skylights are now included in West -facing fenestration area if the skylights are tilted to the w-.st or tilted in any- direction nydirection when the pitch is less than 1:12. See § 151(f)3C and in Section 3.2.3 of the Residential Manual 2) Enter values in this column are. either NFRC Rated value or from Standards default Table 116A. 3). Indicate source either from NFRC or Table I I6A, 4) 'Enter values in this column from NFRC or from Standards Default Table 116B or adjusted SHGC from WS -3R. 5) Indicate source either from NFRC or Table 116B. 6) Shading Devices are defined in Table 3-3 in the Residential- Manual and see WS -3R to calculate Exterior Shading devices. 7) See Section 3.2.4 in the Residential Manual. HVAC SYSTEMS Heating Equipment Minimum Type and Capacity, Efficiency (f{,.:► -pace, heat pump,oiler etc. AFUE or HSPF :tt?'� Vin' lc• Distribution Type and Location Duct or Piping Thermostat Configuration ducts attic 'etc. R -Value T (split or package) iG •Z Z Cooling Equipment Type and Capacity Minimum (A/C, heat pump, evap. Efficiency Duct Location cooling) SEER or EER attic, etc. Duct Thermostat Configuration R -Value Type split or package) .90"54L(' A7MC Z Residential Compliance Forms April 2005 SEALED DUCTS and TXVs (or Alternative Measures) A signed CF -4R Form must be provided to the building department for each home for which the following. are required. Sealed Ducts all climate zones Installer testing and certification and HERS rater field verification re uired. Check box if system meets'criteria of a "Standard" system. Standard system is one gas-fired water heater per TXVs, readily accessible (climate zones 2 and 8-15 only) rim Installer testing and certification and HERS Rater field verification required.) not allowed. Refrigerant Charge (climate zones 2 and 8-15 only) (Installer testing and certification and HERS Rater field Check box when using Preapproved Alternative Water Heating table, Table 5-4 in Chapter. 5 in the Residential verification required.) II Alternative to Sealed Ducts and Refrigerant Charge /TXVs (See Package D. Alternative Package Features for ❑ Project Climate Zone in the RM Appendix B Table 151-C, Footnotes 7-14. OR For additions and alterations, duct systems that are not documented to have been previously ❑ sealed as confirmed through field verification and diagnostic testing in accordance with procedures in the Residential ACM Manual and duct systems with more than 40 linear feet in unconditioned spaces shall meet the requirements of Section 150(m) and duct insulation requirements of Package D. WATER HEATING SYSTEMS Svctemc serving single dwelling units Water Heater Type/Fuel Type Check box if system meets'criteria of a "Standard" system. Standard system is one gas-fired water heater per ❑ dwelling unit. If the water heater is a storage type, 50 gallons is the maximum capacity and recirculation system is Capacity (gaeons not allowed. ❑ Check box when using Preapproved Alternative Water Heating table, Table 5-4 in Chapter. 5 in the Residential Manual. No water heating calculations are required, and the system complies automatically. Check box if system does not meet criteria of "Standard" system, and does not comply with the Preapproved ❑ Alternative Water Heating table. In this case, the Performance Method must be used and must be included in the submittal Check box to verify that a time control is required for a recirculating system pump for a system. serving multiple ❑ units Svctemc serving single dwelling units Water Heater Type/Fuel Type Distribution Type Number in System Rated Input'Tank (kw or Btdpv) Capacity (gaeons Ener y Factor or Thermal Efficient Standby Loss % Tank External Insulation R -Value Svstem servine multiple dwelline units Water Heater Type Distribution Type Number in System Rated Inputs (kw or Btu/hr(gallons) Tank Capacity Energy Factor' or Thermal Efficient Standby Loss % Tank External Insulation R -Value 1) For small gas storage water heaters (rated inputs of less than or equal to 75,000 Btu/hr), electric resistance, and heat pump water heaters, list Energy Factor. For large gas storage water heaters (rated input oFgreater than 75,000 Btu/hr), list Rated Input, Recovery Efficiency, Thermal Efficiency and Standby Loss. For instantaneous gas water heaters, list Rated Input and Thermal Efficiencies. Pipe Insulation.(kitchen lines >_ 3/4 inches) All hot water pipes from the heating source to the kitchen fixtures that are 3/4 inches or greater in diameter shall be thermally insulated as specified by Section I b0 0) 2 A or 150 0) 2 B. Residential Compliance Forms April 2005 alp r CERTIFICATE OF COMPLIANCE: RESIDENTIAL (Page 4 of 5) . CF- Pro'ect Title l I' Lit Date / SPECIAL FEATURES NOT REQUIRING HERS VERIFICATION (add extra sheet: if necessary) Indicate which special features are part of this project. The list below represents special features relevant. to the Prescriptive SPECIAL FEATURES REQUIRING HERS RATER VERIFICATION d extra sheets if necessa Indicate to the HERS Rater which credits are part of this project and n -,ed verification. Feature Required Forms if applicable) De�cri tion Duct.Sealing CF -6R part 4 of 12 _ . Refrigerant Charge CF -6R part 5 of'12 Thermostatic Expansion Valve CF -6R part 6 of 12 Residential Compliance Forms September 2005 Feature Required Forms if applicable) Description ❑ Metal Framed Walls CF -1R ❑ Radiant Barriers CF -1R ❑ Exterior Shades WS -4R N/A; Performance Calculation ❑ Cool Roof Required. Attach.CRRC Label to Forms. Dedicated Hydronic Heating Performance Calculation ❑ System Required; Attach Run to Forms. Performance Calculation ❑ Combined Hydronic System Required; Attach Run to Forms. N/A; Performance Calculation ❑ Gas Cooling Required. ❑ Buried Ducts N/A; Indicate on buildin lans. See Section 5.6.2 Distribution ❑ Kitchen Pipe Insulation Systems in Residential Manual. See Table 5-13 or use ❑ Multiple Water Heaters Per Performance Calculation and Dwelling Unit attach Run to. Forms. Central Water Heating System Performance Calculation and ❑ Serving Multiple Dwellings attach Run to Forms. ❑ Non-NAECA Large Water CF -1R Heater : See Table 5-13 or use ❑ Indirect Water Heater Performance Calculation and attach Run to Forms See Table 5-13 or use ❑ Instantaneous Gas Water Heater Performance Calculation and attach Run to Forms See Table 5-13 or use 0 Solar Water Heating System Performance Calculation and - attach Run to Forms Performance Calculation and ❑ Wood Stove Boiler attach Run to Forms SPECIAL FEATURES REQUIRING HERS RATER VERIFICATION d extra sheets if necessa Indicate to the HERS Rater which credits are part of this project and n -,ed verification. Feature Required Forms if applicable) De�cri tion Duct.Sealing CF -6R part 4 of 12 _ . Refrigerant Charge CF -6R part 5 of'12 Thermostatic Expansion Valve CF -6R part 6 of 12 Residential Compliance Forms September 2005 CERTIFICATE OF. COMPLIANCE; RESIDENTIAL (Page 5 of 5): CF 1R Project TitleDate roiE- Jw �.�/�o� ti COMPLIANCE STATEMENT' This certificate of compliance lists -the building features and specifications needed to comply ,with Title 24,:Parts .1 and 6 of the California Code,of Regulations,'and the.'administrative regulations to irnplement 'them. This certificate,has;been signed by the individual with overall design responsibiility.'The undersigned recognizes that compliance: using duct design, duct sealing, verification of refrigerant charge and TXVs.insulation installation.guality --and building. envelope.sealing require. installer testing: and, .certification and field verification by an_approved HERS rater. ,� , Designer or Owner <ei Business and Professions Code • DOCumentatlon.Author 71., Name: Name: l s d i _ Title/Firm: Title/Firm: S�kyv —M., PtxxrlE A G a Address: Address: Zdt tial m Oe6e�c •k c Telephone: ` Telephone:.: (00 Octo OU -7 09 License #: 37A Y 9 3,% t. ZU. (signature)': (date). (signature) (date)' Enforcement Agency, y . � � r�, +,ayp ,- 4s � � a•r Y �[G =. $g ,Y r MISS ilYS� INSTALLATION CERTIFICATE(Page 1 of 12) CF -6R Site ddress — Permit Number An installation certificate is required to be posted at the building site ormade 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). WATER HEATING SYSTF.MS - Distribution CEC Certified Type Heater Mfr Name & (Std; Point- Type 'Model Number of -Use etc) If k of Rated Input External Recirculation, Identical (kW or Tank Volume Efficiency Standby Insulation Control pe Systems Btu/hr)l(gallons) EF, RE)2 Loss % 2 R-value2 ' 1 For small gas storage (rated input of 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 (RE), Thermal Efficiency, Standby Loss and Rated Input. For instantaneous gas water heaters, list Thermal 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 -IR, all hot.water piping >_ 3/4 inches in diameter that runs 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 I I L Central Water Heating in Buildings with Multiple Dwelling Units (required for prescriptive) ❑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 ✓ ❑ 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 -TR) 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: Copies to: BUILDING DEPARTMENT, HERS RATER (IF APPLICABLE) BUILDING OWNER'AT.00CUPANCY Residential Compliance Forms April 2005 INSTALLATION CERTIFICATE (Page t of 12) CF -6R Site Address Permit Number 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: Item Manu facturerBrand. Name (GROUP LIKE RODUCTS) Total Product U -factor Product SHGC Quantity of Area Exterior # of Like Product Square Shading Device Comments/Location/ (5CF-IRvalue z—CF-IRvalueZ Panes O tions Feet or Ovcrhang Special Features 1. General Contractor (Co. Name) OR Owner 2. OR Window Distributor 3. Signature Date . Installing Subcontractor (Co. Name) OR - 4. General Contractor (Co. Name) OR Owner 5. OR Window Distributor 6. Signature Date Installing Subcontractor (Co. Name) OR 7. General Contractor (Co. Name) OR Owner 8. OR Window Distributor 9. 10. 11. 12. 13. 14. 15. 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 -1R. Alternatively, installed weighted average U -factors for the total fenestration areaare less than or equal to values from CF -1R. If using default table SHGC values from § 116 identify whether tinted or not. ✓ ❑ 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) 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 Copies to: Building Department, HERS Rater (if applicable) Building Owner at Occupancy tcestdential Compliance Forms April 2005 INSTALLATION CERTIFICATE (Page 3 of 12) CF -6R Site Address Permit Number 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 pro-ided to the building department (upon request) and the building owner at occupancy, per Section 10-103(a). HVAC SYSTEMS: Heating Equipment Equip Type . k .heat um CEC Certified Mfr. # of Name and Model Identical Number Systems Efficiency � (AFUE, etc.) 2CF-IR value) Duct Location attic etc. Duct or Piping R -value Heating Load Btu/hr � Heating Capacity ' Btu/hr tt>ers. !sr•� K.4iE i. i AftIC. 'p• 2 TmGGt� p� ,�Z•DSax e 4'Z .DOv Cooling Equipment Equip Type ,(pkg. heat um CEC Certified Mfr. # of Name and Model Identical Number Systems Efficiency t : Duct (SEER or EER) Location zCF-1R value) attic etc. Duct R -value Cooling Load Btu/hr Cooling Capacity Btu/hr ,�Z•DSax e 4'Z .DOv 1. > symbol reads greater than or equal to what is indicated on the CF -IR value. Include both SEER and EER if compliance credit for high EER'air conditioner is claimed. ✓ CJI I, 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 -IR) submitted for ca)mpliance with the Energy Efficiency Standards for residential, buildings, and 3) equipment that meets or exceeds the appropriate. requirements for manufactured devices (from the Appliance Ef cienc /ations or Part 6), where applicable. Installing Subcontractor (Co. Name) OR General Contractor(Co; Name) OR Owner Signa Date: Copies to: BUILDING DEPARTMENT, HERS RATER (IF APPLICABLE) BUILDING OWNER AT OCCUPANCY Residential Compliance Forms April 2005 INSTALLATION CERTIFICATE INSTALLER (Page 4 of 12) CF -6R Site Address • � ^� Permit Number- umber INSTALLER COMPLIANCE STATEMENT FOR DUCT LEAKAGE INSTALLER COMPLIANCE STATEMENT The building was: ✓ OTested at Final ✓ O Tested at Rough -in INSTALLER VISUAL INSPECTION AT FINAL CONSTRUCTION STAGE: ❑ 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. ❑ If the house rough -in duct leakage test was conducted without an air handler installed, inspect the ection poen between the air handler and the supply and return plenums to verify that the connection poi ar ealed. ❑ Inspect all joints to ensure that no cloth backed rubber adhesive duct tape is used��.-�/5,� ✓ 0 DUCT LEAKAGE REDUCTION Procedures for field verification and diagnostic testinp afair 4vtrihnBon cvctome nro nvnilahlo is, vAriLf dnnn—n - v 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 ✓ MoMeasured 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: ✓ ✓ 3 Pass if Leakage Percentage—< 6% for Final or:5 4% at Rough -in: 7O ❑ Pass ❑ Fail 100 x Line #__I) /ine # 2 ; d 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 t 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 Change -Out. Enter Reduction in Leakage for Altered Duct System 6 Line # 4 Minus Line # 5 —(Only if Applicable) 7 Enter Tested Leakage Flow in CFM to Outside (Only if Applicable) ✓ ✓ 8 Entire New Duct System - Pass if Leakage Percentage <— 6% for Final or:5 4% at Rough -in ❑ Pass ❑ Fail 100 x Line # 5 / Line # 2)11 TEST OR VERIFICATION STANDARDS: For Altered Duct System and/or HVAC Equipment Change- ✓ Vol Out Use one of the following four Test or Verification Standards foy 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)]] 11 and Verification by Smoke Test and Visual Inspection ❑ Pass ❑ Fail 12 Pass if Sealing of all Accessible Leaks and Verification by Smoke Test and Visual Inspection ❑ Pass ❑ Fail Pass if One of Lines # 9 through # 12 pass ❑ Pass ❑ Fail ✓ LI I, the undersigned, verify that the above diagnostic test results were performed in conformance with he 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 Eff ciency standards. Installing Subcontractor (Co. Name) OR General Contractor (Co. Name) OR Owner Date: 1114/'per Copies to: BUILDING DEPARTMENT, HERS RATER (IF APPLICABLE) BUILDING OWNER AT OCCUPANCY Residential Compliance Forms April 2005 INSTALLATION CERTIFICATE (Page 5 of 12) CF -6R Site Address Permit Number s� -los (ei L)t si"O- ✓ ❑ THERMOSTATIC EXPANSION VALVE (TXV) Procedures for field verification 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 ✓ ❑ Yes ❑ No the system and installation of the specific equipment ❑ ❑ shall be verified. Yes is a pass Pass Fail ✓ 0 -REFRIGERANT CHARGE MEASUREMENT Verification for Required Refrigerant Charge and Adequate Airflow for Split System Space Cooling Systems without Thermnstatic Fxnnncinn Vnlvec Outdoor Unit Serial # OF I Location OF Outdoor Unit Make OF N Outdoor Unit Model OF Cooling Capacity Btu/hr Date of Verification OF Date of Refrigerant Gauge Calibration (must be checked monthly) Date of Thermocouple Calibration L (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 RA CM, Appendix RD2. Note: The system should be installed and charged in accordancewith the manufacturer's specifications before starting this procedure. Measured Temperatures Supply (evaporator leaving) air dry-bulb temperature (Tsupply, db) OF I Return (evaporator entering) air dry-bulb temperature (Treturn, db) OF Return (evaporator entering) air wet -bulb temperature (Treturn, wb) OF N Evaporator saturation temperature (Tevaporator, sat) OF Suction line temperature (Tsuction, db) OF Condenser (entering) air dry-bulb temperature (Tcondenser, db) OF Sunerheat Charge Methnd CAnnIntinnc fnr Refrioernnt rhara, Actual Superheat. = Tsuction, db — Tevaporator, sat OF I Target Superheat (from Table RD -2) OF Actual Superheat — Target Superheat (System passes if between -5 and +5°F) OF Temperature Split Method Calculations for Adequate Airflow .Smit Afvthnd (Wrv/n/inn is not noror , ;i diJo . neo 4;..4. 1 ,.,1:, : _L__ 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 - 3°F and +3°F or, upon remeasurement, if between -3°F and -100°F OF Residential Compliance Forms April 2005 n INSTALLATION CERTIFICATE (Page 6 of 12) CF=6R Site Address - Permit Number �v� ZOO c�sren' • 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. ✓ ❑ Yes ❑ 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. Wei h -In 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) t -asured 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 meas:arements. If corrective actions were taken, both criteria must be remeasured and recalculated. ✓ ❑ Yes ❑ No I System Passes 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 j Residential Compliance Forms April 2005 I INSTALLATION CERTIFICATE (Page 7 of 12) CF -6R Site Address�Permit Number � v� 4 MISCELLANEOUS CREDITS /13D IiAGNOSTIC 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. ✓ ❑ LESS THAN 12 LINEAL FEET OF SUPPLY DUCT 011TSTDF nF cnNnTT1nNFn cPArF ✓ ❑Yes ❑No I Less than 12 lineal feet of supply duct outside of conditioned space. Yes to this compliance credit is a pass ✓ ❑ Pass I ✓ ❑ Fail ✓ ❑ SUPPLY DUCTS LOCATED IN CONDITIONED SPACE COMPLIANCE CREDIT ✓ ❑ Yes 10 No I Ducts are located within the conditioned volume of building. Yes to this compliance credit is a pass ✓ ❑ Pass ✓ ❑ 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 Adequate airflow verified ✓ ❑ Yes ❑ 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 ✓ ❑ Yes 11ONo I Duct sizes, duct system layout and locations of supply & return registers match the duct system design plan Yes to all is a pass 1 ❑ Pass ✓ ❑Fail v LJ SUPPLY DUCTS SURFACE AREA REDUCTION COMPLIANCE CREDIT Attic Crawl Space R-4.2 Deeply Duct Surface Basement Covered Covered Other Diameter Area R-6.0 Surface Area R-8.0 Surface Area ❑ ❑ ❑ ❑ ❑ ❑ ❑ Pass ❑Fail ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑. ❑ ❑ ❑ ❑ ❑ 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Total Surface Area for Each R -Value = ✓ ❑ Yes ❑ No tches Performance's CF -1R? ✓. ✓ Yes to all is a pass 1 ❑ PaSE ❑ Fail V ❑ BTJRTF,D nT1CT5 nN TT -TF. CRTT.TNr• r'nMDT TANd V i D r%r-r ❑ Yes Q No Buried Ducts on the Ceiling ❑ Yes ❑ No Verified High Insulation Installation Quality v ✓ Yes to ducts stem design, supply duct. surface area reduction and this compliance credit is a ass ❑ Pass ❑Fail ✓ ❑ nF.F.PT:V RTTRTFn nT1rTC rnMUT TANrL' I-DVnrm Copies to: BUILDING DEPARTMENT, HERS RATER (IF APPLICABLE) BUILDING OWNER AT OCCUPANCY Residential Compliance Forms April 2005 ❑ Yes ❑ No Deeply Buried Ducts ❑ 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 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 ✓❑ FAN WATT DRAW Procedures or measuring the air handler watt draw are available in RACM, Appendix 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 Measured Fan Flow enter total cfm• from airflow verification Enter results of Watts/cfm ❑ RE4.1.1 Diagnostic Fan Flow Using Flow Capture Hood ❑ RE4.1.2 Diagnostic Fan Flow Using ✓ ❑ Yes ❑ No Measured fan watt/cfm draw is equal to or lower than the fan watt/cfm draw documented in CF -1R ❑ ❑ Yes is a pass Pass Fail ✓ ❑ ADEQUATE AIRFLOW VERIFICATION Procedures -for measuring the airflow are available in RACM. Annendix RF.3 i ✓ Method For Airflow Measurement ❑ RE4.1.1 Diagnostic Fan Flow Using Flow Capture Hood ❑ RE4.1.2 Diagnostic Fan Flow Using Plenum Pressure Matching ❑ . RE4.1.3 Diagnostic Fan Flow Using Flow Grid Measurement ❑ Yes ❑ No Duct design exists on plans Measured Airflow: Rated Tons cfm/ton ✓ ✓ ✓ ❑ Yes ❑ No Measured airflow is greater than the criteria in Table RE -2 Yes is a 2ass ❑ I Pass F ❑ I Fail Watts chn Watts/cfm TStal cfm ctin/ton ✓ ❑ MAXIMUM COOLING CAPACITY Procedures for det ining maximum cooling load capacity are available in RACM, Appendix RF3. 1 ✓ ❑ Yes ❑ No Adequate airflow verified (see adequate airflow credit) 2 ✓ ❑ Yes ❑ No Refrigerant charge or TXV 3 ✓ ❑ Yes ❑ No Duct leakage reduction credit verified 4 ✓ ❑ Yes ❑ No Cooling capacities of installed systems are:5 to maximum cooling capacity indicated on the Performance's CF -1R and RF -3. If the cooling capacities of installed systems are > than maximum ✓ 5 ✓ ❑Yes ❑ No cooling capacity in the CF -1R, then the electrical input for the installed systems must be S to electrical input in the CF -1R. ❑ Yes to 1, 2 and 3; and Yes to either 4 or 5 is a pass Fass Fail ✓❑ HIGH EER AIR CONDITIONER Procedures or veri rcation are available in RACM, Appendix RI. 1 ✓ 1 ❑ Yes ❑ No I EER values of installed systems match the CF -1R 2 ✓ ❑ Yes ❑ No Fors lits stem, indoor coil is matched to outdoor coil ✓ ✓ 3 `� ❑ Yes ❑ No Time Delay Relay Verified (If Required) ❑ ❑ Yes to 1 and 2• and 3 If Required) is a ass Pas: Fail C istalling Subcontractor (Co. Name) OR General ontractor (Co. Name) OR Owner ignature: Date: es to: BUILDING 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 ZOS i�3_ lel )0*1' 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 provi Jed to the building department (upon request) and the building owner at occupancy, per Section 10-103(a). BUILDING ENVELOPE LEAKAGE DIAGNOSTICS ✓ ❑ ENVELOPE SEALING INFILTRATION REDUCTION Procedures for field verificationand 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 I ❑ ❑ Measured envelope leakage less than or equal to the required level from Yes No CF -1R? 2. ❑ Yes ❑ No Is Mechanical Ventilation shown as required on the CF -1R? 2a ❑ ❑ If Mechanical Ventilation is required on the CF -1R (`Yes' in line 2), has it Yes No been installed? ❑ ❑and Check this box `yes' if mechanical ventilation is required (`Yes' in line 2) 2b. Yes No ventilation fan watts are no greater than shown on CF -1R. Measured Watts = ❑ ❑ Check this box "yes" if measured building infiltration (CFM @ 50 Pa) is 3. Yes No greater than the CFM @ 50 values shown for an SLA of 1.5 on CF -1R 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 foran 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 inline 1 and line2, 2a, and 2b, or c. Yes in line 1 and Yes in line 4. ❑ ❑ Otherwise fail. I Pass Fail ✓ ❑ I, the undersigned, verify that.the building envelope leakage meets the requirements claimed for bu=lding 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, HERS RATER (IF APPLICABLE), BUILDING OWNER AT OCCUPANCY nesiaenual Compliance Forms April 2005 INSTALLATION CERTIFICATE (Page 10 of 12) CF ,6R Site Address L) o:�to Permit Number , Insulation Installation Quality Certificate ✓ ❑ 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. ✓ ❑ Installation meets all applicable requirements as specified in the High Quality Insulation Installaton Procedures CM, Appendix RH) ✓ FLOOR ❑ Yes ❑ No ❑ NA All floor joist cavity insulation installed to uniformly fit the cavity side-to-side and end-to-end ❑ Yes ❑ No ❑ NA Insulation' in contact with the subfloor or rim joists insulated ❑ Yes I ❑ No ❑ NA Insulation properly supported to avoid gaps, voids, and compression ✓ WALLS ❑ ❑ ❑ Wall stud cavities caulked or foamed to provide an air tight envelope Yes No NA ❑ Yes ❑ No ❑ NA Wall stud cavity insulation uniformly fills the cavity side-to-side, top-to-botton-, and front -to -back ❑ ❑ ❑ No gaps Yes I No NA ❑ -Yes ❑ No ❑ NA No voids over 3/4" deep or more than 10% of the batt surface area. ❑ ❑ ❑ Hard to access wall stud cavities such as; corner channels, wall intersections, aad behind Yes No NA tub/shower enclosures insulated to proper R -Value ❑ Yes ❑ No ❑ NA Small spaces filled H❑❑ oNA Rim- oists insulated ❑'❑ Loose fill wall insulation meets or exceeds manufacturer's minimum weight -per -square -foot o NA 1 requirement ✓ ROOF/CEILING PREPARATION ❑ Yes ❑ No ❑ NA 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 ❑ ❑ ❑ 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 ❑ Yes ❑ No ❑ NA 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 Knee walls insulated or prepared for blown insulation ❑ Yes ❑ No ❑ NA Area under equipment platforms and cat -walks insulated or accessible for blo7n insulation ❑ Yes ❑ No ❑ NA Attic rulers installed Residential Compliance Forms April 2005 INSTALLATION CERTIFICATE Site Address A�Ze ✓ R OF/CEILING BATTS (Page ll of 12) CF -6R Permit Number DECLARATION ✓ ❑ 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: BUI.LDING DEPARTMENT; HERS RATER (IF APPLICABLE), BUILDING OWNER AT OCCUPANCY Residential Compliance Forms April 2005 Yes. . No NA No gaps ❑ ❑ ❑ Yes No NA No voids over % in. deep or more than 10% of the batt surface area. ❑ ❑ ❑ Yes No NA Insulation in contact with the air -barrier ❑ ❑ ❑ - Yes No. NA Recessed light fixtures covered . ❑ 0 ❑ Net free -ventilation area maintained at eave vents Yes No NA ✓ ROOF/CEILING LOOSE -FILL.- ❑ ❑ ❑. Yes No NA Insulation uniformly covers the entire ceiling (or.roof) area from the outside of 311 exterior walls. ❑ ❑ ❑ Yes No NA Baffles installed at eaves vents or soffit vents - maintain net free -ventilation area of eave vent ❑ ❑ ❑ Yes No NA Attic access insulated ❑ ❑ ❑ Yes I No NA Recessed light fixtures covered ❑ ❑ ❑ Yes No NA Insulation at proper depth — insulation rulers visible and indicating proper deptl- and R -value ❑ ❑ ❑ 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 ninimum 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 verb that the manufacturer's minimum weight and thickness has been aci ieved for the target R -value. CF -6R only) DECLARATION ✓ ❑ 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: BUI.LDING DEPARTMENT; HERS RATER (IF APPLICABLE), BUILDING OWNER AT OCCUPANCY Residential Compliance Forms April 2005 m INSTALLATION CERTIFICATE (Page 1.2 of 12) CF -6R Site Address /'% rC . - Permit Numbe- County Subdivision Lot Number 1 Description of Insulation (Formerly IC -1 Form) 1. RAISED FLOOR Material ' Brand Name Thickness (inches) Thermal Resistance (R -Value) 2.. SLAB FLOOR%PERIMETER 1 Material Brand Name Thickness (inches) Thermal Resistance (R -Value) Perimeter Insulation Depth (inches) OR Window Distributor 3. EXTERIOR WALL Signature Date Frame Type (if applicable) A. -Cavity Insulation General Contractor (Co. Name) OR Owner . Material Brand Name Thickness (inches) Thermal Resistance (R -Value) B . Exterior Foam Sheathing Material Brand Name Thickness (inches) Thermal Resistance (R -Value) 4. FOUNDATION WALL Material Brand Name Thickness (inches) Thermal Resistance (R -Value) 5. CEILING Batt or Blanket Type Brand Name Thickness (inches) Thermal Resistance (R -Value) Loose Fill Type Brand Contractor's min installed weight/ftz Ib , 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) Declaration ✓ ❑ 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 (if applicable) Signature Date Installing Subcontractor (Co. Name) OR 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