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AR (05-1548)Tdf 4 4a�rw BUILDING & SAFETY DEPARTMENT P.O. Box 1504 - (760),777-7012 78-495 CALLE TAMPICO a } FAX (760) 777-7011 LA QUINTA, CALIFORNIA 92253 INSPECTION REQUESTS (760) 777-7153 BUILDING PERMIT Application Number Property Address . . . . . . APN: Application description . . . Property Zoning . . . . . . . Application valuation . . . . Owner --------------------------------- STAFFORD LYA T 53995 AVENIDA MENDOZA LA QUINTA, CA 92253 05-00001548 Date 4/25/05 53995 AVENIDA.MENDOZA 774-172-022-12 -000000-' ADDITION - RESIDENTIAL COVE RESIDENTIAL 3512 Contractor --------------------------------- Owner Other struct info . . . . . CODE EDITION 2001 CBC # BEDROOMS _ 1.00 FLOOD ZONE NO 1ST FLOOR SQUARE FOOTAGE 80.00 P.O. Box 1504• gwo VOICE (760) 777-7012 78-495 CALLS TAMPICO FAX (760) 777-7011 LA QUINTA, CALIFORNIA 922$3 TlOt 4 aINSPECTIONS (760) 777-7153 BUILDING & SAFETY DEPARTMENT Application Number: Applicant: t�.�rro Applicant's Mailing Address: Date: 45 - Architect or Engineer: Architect or Engineer's Address: Lic. No.: BUILDING PERMIT DECLARATIONS LICENSED CONTRACTOR'S DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professionals Code, and my License is in full force and effect. License Class License No. Date Contractor OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury that I am exempt from the Contractors' 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 Contractors' 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).): U I, as owner of the property, or my employees with wages as their sole compensafion, 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 or 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, 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.). U 1 am exempt under Sec. B.& P. f this rea Date �� Owner /dar., (ERS' OMPENSATION DECLARATION I hereby affirm under penalty of pedury one of the following ions_ I have and will maintain a certificate of consentnsure 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 Policy Number 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, ao agree that, if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provi ns. `'.h )ll Date ' Applicant WARNING: FAILURE TO SECURE WOR RS' COMPENSATIONEY'S ERAG IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($0), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATT FEES. 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.). Lenders Name Lenders Address 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 informatio i correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this county toenn the above-mentioned property for inspection purposes. at Z Signat&rre (Applicant o Agent): r Application Number : n.05=00001548 ---------------------------------------------------------------------------- Permit . . . . . . BUILDING PERMIT Additional desc Permit Fee . . . . 63.00 Plan Check Fee 40.95 Issue Date . . . . Valuation . . . . 3512 Expiration Date 10/22/05 Qty Unit Charge Per Extension BASE FEE 45.00 2.00 9.0000 THOU BLDG 2,001-25,000 18.00 ---------------------------------------------------------------------------- Permit . . . . ELECT.- ADD/ALT/REM Additional desc . . Permit Fee . . . . 17.80 Plan Check Fee 4.45 Issue Date . . . . Valuation . . . . 0 Expiration Date 10/22/05 Qty Unit Charge Per Extension BASE FEE 15.00 80.00 .0350 ELEC NEW RES - 1 OR 2 FAMILY 2.80 ---------------------------------------------------------------------------- Permit . . . . . . MECHANICAL Additional desc Permit Fee 24.00 Plan Check Fee 6.00 Issue Date . . . . Valuation . . . . 0 Expiration Date 10/22/05 Qty Unit Charge Per Extension BASE FEE 15.00 1.00 9.0000 EA MECH APPL REP/ALT/ADD 9.00 ---------------------------------------------------------------------------- Permit . . . . . . PLUMBING Additional desc . . Permit Fee . . . . 18.00 Plan Check Fee 4.50 Issue Date . . . . Valuation . . . . 0 Expiration Date 10/22/05 Qty Unit Charge Per Extension BASE FEE 15.00 1.00 3.0000 EA PLB WATER INST/ALT/REP 3.00 ---------------------------------------------------------------------------- Special Notes and Comments 80 SQ. FT. ADDITION TO EXISTING MASTER BEDROOM UNDER EXISTING ROOF.April 25, 2005 1:48:49 PM JJOHNSON ---------------------------------------------------------------------------- Other Fees . . . . . . . ENERGY REVIEW FEE 4.10 STRONG MOTION (SMI) - RES .50 Fee summary Charged Paid Credited Due --------------------------------------------------------- Permit Fee Total 122.80 .00 .00 122.80 Plan Check Total 55.90 ,00 .00 55.90 Other Fee Total 4.60 .00 .00 4.60 Grand Total 183.30 .•00 .00 183.30 At the present time, the Desert Sands Unified School District does not collect fees on garages/carports, covered patiostwalkways, residential additions under 5 00 square feet, detached accessory structures (spaces that do not contain facilities for living, sleeping, cooldng, eating or sanitation) or replacement mobile ho mes. It has been determined that the above-named owner is exempt from paying school fees at this time due to the following reason: Residential Addition 500 Sq Feet or Less EXEMPT This certifies that school facility fees imposed pursuant to Education Code Section 17620 and Government Code 65995 Et Seq. in the amount of $0.00 X 80 S.F. or $0.00 have been paid for the property listed above and that building permits and/or Certificates of Occupancy for this square footage in this proposed project may now be issued. fees Paid By Exempt-Lya Stafford Check No. Name on the check Telephone 831-4779 Funding Exempt By Dr. Doris Wilson Superintendent Fee collected /exer"ted by Patricia Barbuzza Payment Recd Signature V ar "J. .00 Over/Under NOTICE: Pursuant to Government Code SectioK66020(d)(1), this will serve to notify you that the 9U -day approval period in which you may protest the fees o r other payment identified above will begin to run from the date on which the building or installation permit for this project is issued, or from the date on which those amounts are paid to the District(s) or to another public entity authorized to collect them on the District(s) behalf, whichever is earlier. NOTICE: This Document NOT VALID if Duplicated Embossed Original -Building Department/Applicant Copy -Applicant/Receipt Copy - Accounting CERTIFICATE OF COMPLIANCE Desert Sands Unified School District off°^moo 47950 Dune Palms Road < BERMUDA DUNES r Date 4/26/05 La Quinta, CA 92253 U% RANCHO MIRAGE INDIAN WELLS No. 27129 (760) 771-8515 d PLADESEW QUINTA ��QINDIO y�ta t. Owner Lya Stafford APN # 774-172-022 Address 53-995 Avenida Mendoza Jurisdiction La Quinta City La Quinta Zip 92253 Permit # Tract # Study Area Type Residential Addition No. of Units Lot # No. Street S.F. Lot # No. Street S.F. Unit 1 53-995 Avenida Mendoza 80 Unit 6 Unit 2 Unit 7 Unit 3 Unit 8 Unit 4 Unit 9 Unit 5 Unit 10 Comments At the present time, the Desert Sands Unified School District does not collect fees on garages/carports, covered patiostwalkways, residential additions under 5 00 square feet, detached accessory structures (spaces that do not contain facilities for living, sleeping, cooldng, eating or sanitation) or replacement mobile ho mes. It has been determined that the above-named owner is exempt from paying school fees at this time due to the following reason: Residential Addition 500 Sq Feet or Less EXEMPT This certifies that school facility fees imposed pursuant to Education Code Section 17620 and Government Code 65995 Et Seq. in the amount of $0.00 X 80 S.F. or $0.00 have been paid for the property listed above and that building permits and/or Certificates of Occupancy for this square footage in this proposed project may now be issued. fees Paid By Exempt-Lya Stafford Check No. Name on the check Telephone 831-4779 Funding Exempt By Dr. Doris Wilson Superintendent Fee collected /exer"ted by Patricia Barbuzza Payment Recd Signature V ar "J. .00 Over/Under NOTICE: Pursuant to Government Code SectioK66020(d)(1), this will serve to notify you that the 9U -day approval period in which you may protest the fees o r other payment identified above will begin to run from the date on which the building or installation permit for this project is issued, or from the date on which those amounts are paid to the District(s) or to another public entity authorized to collect them on the District(s) behalf, whichever is earlier. NOTICE: This Document NOT VALID if Duplicated Embossed Original -Building Department/Applicant Copy -Applicant/Receipt Copy - Accounting OWNER/BUILDER INFORMATION Dear Property Owner: An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified. For your protection you should be aware that as "Owner/Builder" you are the responsible party of record on such a permit. Building permits are not required to be signed by property owners unless they are personally performing their own work. If your work is being performed by someone other than yourself, you may protect yourself from possible liability if that person applies for the proper permit in his or her name. Contractors are required by law to be licensed and bonded by the State of California and to have a business license from the City or County. They are also required by law to put their license number on all permits for which they apply. If you plan to do your own work, with the exception of various trades that you plan to subcontract, you should be aware of the following information for your benefit and protection: If you employ or otherwise engage any persons other than your immediate family, and the work (including materials and other costs) is $200.00 or more for the entire project, and such persons are not licensed as contractors or subcontractors, then you may be an employer. If you are an employer, you must register with the State and Federal Government as an employer and you are subject to several obligations include State and Federal income tax withholding, federal social security taxes, worker's compensation insurance, disability insurance costs and unemployment compensation contributions. There may be financial risks for you if you do not carry out these obligations, and these risks are especially serious with respect to worker's compensation insurance. For more specific information about your obligations under Federal Law, contact the Internal Revenue Service (and, if you wish, the U.S. Small Business Administration). For more specific information about your obligations under State Law, contact the Department of Benefit Payments and the Division of Industrial Accidents. If the structure is intended for sale, property owners who are not licensed contracts are allowed to perform their work personally or through their own employees, without a licensed contractor or subcontractor, only under limited conditions. A frequent practice of unlicensed persons professing to be contractors is to secure an "Owner/Builder" building permit, erroneously implying that the property owner is providing his or her own labor and material personally. Building permits are not required to be signed by property owners unless they are performing their own work personally. Information about licensed contractors may be obtained by contacting the Contractors' State License Board in your community or at 1020 N. Street, Sacramento, California 95814. Please complete and return the enclosed owner -builder verification form so that we can confirm that you are aware of these matters. The building permit will not be issued until the verification is returned. Very truly yours, CITY OF LA QUINTA DEPT. OF BUILDING AND SAFETY 78-495 Calle Tampico La Quinta, CA 92253 (760) 777/P12 FAX: (76 777 7011 �L �� e'1 (,'WNV'S SIGNATU E �-3 PROPERTY ADDRESS PERMIT NUMBER(S) r SOS p RE=INSPECTION FS DF $30 WILL BE CHARGED 1E TME APPROyEN PLANS AND- IOBR �D ARE EHEDUL� THE SITE FOR 1NSPECtION QU N PA. OF&I�FEV pE BU��oING ODIC bw*o,C r Pirz-o f D. L; rV tr b 1 -- I. Construction is t OT PERMITTED 1 on the following ode Holidays:`:.: 1 1 I New Year's Day I I Dr. Martin Luther I nay, ' President's Day I Memorial Day. i 10' Independetice Labor Day. Veteran's nay:. Thanksgiving Day ' Christmas Day CONCR Slj�-IN PATIO S I afar I , 8o sy F- i j (i.Uo 1310 A) �9^'•ObQ L%[uTINJ" Roo► I "AN ADEQUATELY SIZED DEBRIS CONTAINER IS REQUIRED ON THE JOB SITE DURING ALL. I PHASES OF CONSTRUCTION AND MUST BE ' EMPTIED AS NECESSARY. FAILURE TO DO S0. I MAY CAUSE THE CITY TO HAVE THE CONTAINER I , o DUMPED AT THE EXPENSE OF THE OWNER/ 1 f;ONTRACTOR." jNSTRJCT10N HOURS octn r Ist - April 30 - Friday: a.m. 7:00 a.tQ �� g:00 a.m. to 5:4Q None Code HolidayS q.r:..September 30* Fridy: - 6:00 a.m.', Any: 8:00 am tes:08i None ,a "knent Code HohdayO I U I 2-- FcooQ, PWJ .3. - Fc>u" ID 14 T ( 0 P. . zI �I �I 7 - L I e vAiloIJ al 1 B I a�cKS� _p I I 1 I' I I I I 1 I I I I I I � I CON'MZTE EP?TRY 53-X15 �uEv pg LEGAL DESCRIPTION: ASSESSORS PARCEL_ NUMBER 7 -y d1.7 2,_1 —0 4`2 qq n ,p il Ci i7 SEPTIC TANK— SIZE REQUIRED BY THE HEALTH DEPT. N ZA 7-. I -- SEEPAGE PIT r � U SIr-r-1 -r--1 TE PLAN SCALE 1* -8'' i I ',gAU< zI �I �I �I al 1 B I 1 2X4 HDR 16' WIDE CONC— �\ DRIVEWAY 53-X15 �uEv pg LEGAL DESCRIPTION: ASSESSORS PARCEL_ NUMBER 7 -y d1.7 2,_1 —0 4`2 qq n ,p il Ci i7 SEPTIC TANK— SIZE REQUIRED BY THE HEALTH DEPT. N ZA 7-. I -- SEEPAGE PIT r � U SIr-r-1 -r--1 TE PLAN SCALE 1* -8'' i Cf�61N�r� i DROOM"o 3"', 4' t WA:. HE Li M � � BIFOLD DR BEDROOM 2 0 :N 22X30 ARID 29-6 ,• 4. 1 3' _ 5 • 3'— $ - AccEss �ANtL12 ' � w x r 6 r I` Ll C x i C. J d- CLOSET n I t' 2h 6S.. I W\I.OUVC 5 Rtbwud FOR GO 10 } i� 6rIE1 r- K. POLus9 AIR chi � au4� BATH BEDROOM 3 { r_ ' s ' — — 2' S' —1 1 3 — 8 Jl � CLr & PO,_� 3•' 3 � i 38'• BO? FIRE 1. C.9.0. # 2301 W\ rlf•_AR rr, , I DINING ROOM •� LIVING ROOM o' r- J j IN i CPIOP GLILINC �' i LINE K 0\/t=R�yEAD CABINL- rs 'D 11'-7' 5'—C Ll6'•14 41'7' T' co 4 M G. N x +• •0 V r- A F /-ty SN'Lr & POO RANGE 3 I HOOD OW/Vf=R <a 2 r- ` ELrCLOSING KITCHEN Dw cn sI . S/8r i ;'PL '?' VIP. 90. �'ANiR'r FLOOR. r0 P.00r 314CATING 413 JL G GARAGE�� RooR PfAA.); 2 18'. L6 n W if). >O �OrJ 11 > QLD. C ,eliy PE ua : i SAFETY DE . T. " + ^ l�A N 3 APPROVE W FOR CONSTRUCTION Q MASTER Ln DATE BY ". ATH , 6 GIA ='riOWEF 3r+CLF & PO OWLF Dr O 1 1 + Di (CR y I Nt JVCR�tiEPO Cf�61N�r� i DROOM"o 3"', 4' t WA:. HE Li M � � BIFOLD DR BEDROOM 2 0 :N 22X30 ARID 29-6 ,• 4. 1 3' _ 5 • 3'— $ - AccEss �ANtL12 ' � w x r 6 r I` Ll C x i C. J d- CLOSET n I t' 2h 6S.. I W\I.OUVC 5 Rtbwud FOR GO 10 } i� 6rIE1 r- K. POLus9 AIR chi � au4� BATH BEDROOM 3 { r_ ' s ' — — 2' S' —1 1 3 — 8 Jl � CLr & PO,_� 3•' 3 � i 38'• BO? FIRE 1. C.9.0. # 2301 W\ rlf•_AR rr, , I DINING ROOM •� LIVING ROOM o' r- J j IN i CPIOP GLILINC �' i LINE K 0\/t=R�yEAD CABINL- rs 'D 11'-7' 5'—C Ll6'•14 41'7' T' co 4 M G. N x +• •0 V r- A F /-ty SN'Lr & POO RANGE 3 I HOOD OW/Vf=R <a 2 r- ` ELrCLOSING KITCHEN Dw cn sI . S/8r i ;'PL '?' VIP. 90. �'ANiR'r FLOOR. r0 P.00r 314CATING 413 JL G GARAGE�� RooR PfAA.); 2 FOUNDATION CITY OF QINTA 11'4 ILDING & FETY DEPT. APPR VED FOR CONSTRUCTION DATE BY master bedroom CV 53995 AVENIDA MENDOZA LA QUINTA , CA 92253 , z1g 11'10 1/5 1/5 10) 0k, (2) 2-9 " STRAP 2/4 MSTC 52 SIMPSON _ (i%g C9, wall panels- 4' (2) ALT �Rt�_(; -,.JWALL- 2-8 _ l 4 F0 t U5 1/5 2/4 �q CONT. GALVANIZED SHEET METAL PLASTER SCREED 26 GA. MIN.PAINT TO MATCH PLASTER. FINISH FLOOR PAINT EXPOSED CONC. TO MATCH a PLASTER. N FINISH GRADE STUCCO ON 2 x WOOD STUDS @ 16 O.C. M PTDF r� I 11/2" DRYWALL I 5/8" DIA. i� ANCHOR BOLT W/2"x2"x3116" SQ.WASHEF n PTDF CO�JCREI AND FOOTIN �/� QUINTA jSEL SI ICD -1 SAFETY DEPT" ""ROVED TRUCTION _ 1L/11L/11L/111�11�/1�_ DATE BY VE SOIL WED AREAS FIN. GRADE c�1 ` % IN EXTEND NOT LESS THAN 12" UNDISTURBED SOIL #4 CONT. T & B \� 1/2" GYPSUM BOARD 5/8" DIA. ANCHOR BOLT W/2"x2"x3/16" SQ.WASHER 1'-0" ..'.WALL SCHEDULE WOOD STRUCTURAL PANEL (4'-0' MINIMUM) WIDTH x3/8" CDX OR EQUAL W/8d NAILING, 6" @ EDGES, O 12"@ INTERMEDIATE SUPPORTS, W/2 ANCHOR BOLTS @ 24 O.C. ALTERNATE BRACED PANEL (2'-8' MIN) 3/8' MINIMUM PLYWOOD SHEATHING NAILED WITH 8d COMMON AND BLOCKEDAT ALL PLYWOOD EDGES, TWO O ANCHOR BOLTS @ QUARTER PANEL POINTS. EACH PANEL END STUD TO HAVE HPAHD22 HOLOOWN. SEE DETAIL. NAILING TO BE 8", @ EDGES OR 12" AT INTERMEDIATE SUPPORTS. OINTERIOR '3 SHEARWALL GYPSUM BOARD '/:" THICK SHEATHING NAILED WITH 8d COMMON AND BLOCKED BY 4' WIDE BOTH SIDES OR 8'-0' ON STUDS SPACED LESS THAN 24" O.C. AND NAILED @ 7.O.C. WITH MINIMUM #11 GAGE NAILS 1'/." LONG, 7/16" HEAD, DIAMOND POINT GALVANIZED. MAXIMUM HEIGHT FOR ALTERNATE BRACED PANELS IS 10'-0" TOP UPPER PL TOP PLATE BRACED PANEL ALTERNATE BRACED PANEL \ TYPICAL BRACED PANEL TYPICAL I O j / foiuu.: fiiiiiiiiiiiiiiiiiiiiiiiieiiiiii' lw'Am�l m DEVICE WITH AN ED UPLIFTCAPACITY PUONDSTYPICAL AT D EACH PANEL. H022,AS SHOWN. 1 TYPICAL TYPP 3/8' TRICK (MIN) WOOD TRUCTURALPANEL TWO ANCHOR BOLTS, ONE AT EACH SHEATHING NAILED WITH W0 COMON IOR PANEL QUARTER POINT, INSTALLED GAQNIZED BOX NAILS NAILED WACCIR - ACCORDANCE WITH SECTION 1 "m %:.DAN' WITH TABLE 23.1-Q AND ALt PANEL 1806.6, TYPICAL EACH BRACED WALL EDG TO BE BLOCKED, TYPICAL EACH PANEL. BRACED WALL PANEL. 4" CONC. SLAB W/ / I /10WWM .010VISQUEEN 53-995 AVENIDA MENDOZA .010 WITH 2" SAND ON TOP 17"oo"o,0000, 0� 11 I NEW EXI., 2 x STUDS ® WO. G. W/ 2 x TREATED SILL PLATE W/ 5/,W m X 10" AD a 2=0116" W. WASHER ® CORNERS 4 OPENINC75 3 SPLICES, SPACE ® 4'-0" o.c. U.N.O. ® SHEAR WALLS. 31/2 " THK. CONCRETE SLAB 40 MILL VISOUEEN UNDER 'CLEAN SAND (TYP) x /ID XXF. m CL. SLAB NT. TOP AND BOT% LAP. 24 MIN. (`I'YPIGAU 1 ITY OF LA QUINTA BUILDING & SAFETY DEPT. APPROVED FOR CONSTRUCTION DATE By 53-995 AVENIDA MENDOZA 5 ELECTRICAL & MECH ma 4 11'4 -ato OF LA QUINTA ;�-DING & SAFETY DEPT. FOR APPROVED CONSTRUCTION ter bedrgpm TIEICIOIEXISTING DUCTS FOR HEATING & COOLING 3'6 8'4 RFC; AIS I proposed adition to the master bedroom O rn Ll U taFc I 23'2 4X2 SLD WDW 4 X4 SLD WDW 53995 AVE N I DA M E N DOZA Externall walls to have R-15 LA QUI NTA , CA 92253 insulation. Cellings to be with R-38 � � 00 } V CERTIFICATE OF COMPLIANCE: RESIDENTIAL Project Title Project Addres r3 ,IF D d 4-x /_ -m iance Method (Package or Computer) ge .1 of 3) CF -IR IV J ate Building Permit # Plan Check / Date Field Check / Date GENERAL INFORMATION Total Conditioned Floor Area ft Average. Ceiling Height: ft Conditioned Slab Floor Area ft2 Building Type: Single Family Addition (check one or more) Multi -Family Existing -Plus -Addition Front Orientation: 'North / South / East / West / All Orientations (input front orientation in degrees from True North and circle one) Number of Stories _� P Number of Dwelling Units: F Floor Construction Type: Qab Raised Floor (circle one or both) RADIANT BARRIER (required in climate zones 2, 4, 8-15) Required for this submittal_ yes no BUILDING ENVELOPE INSULATION Component Frame Type Cavity Sheathing Total R- Assembly Location/Comments Type wd = wood Insulation Insulation Value' U -Factor' (attic, garage, typical, etc.) stl = steel R -Value R -Value Wall Wall Roof Roof Floor Floor Slab Edge ror prescriptive compuance, t o[ai n -value ana Assembly U -1 -actor are not required for a wood -framed wall that meets cavity R value insulation requirements for the Prescriptive Package. FENESTRATION January 5, 2001 CERTIFICATE OF COMPLIANCE: RESIDENTIAL (Page 2 of 3) r , CF -IR Project Title Date HVAC SYSTEMS Note: Input hydronic or combined hydronic data under Water Heating Systems, except Design Heating Load. Distribution Heating Equipment Minimum Type and Duct or Heat Pump Type (furnace, beat Efficiency Location Piping Thermostat Configuration pump, etc:) (AFUE or HSP ducts, attic, etc. R -Value Type (split or package) `S - Cooling Equipment Minimum Duct Heat Pump Type (air conditioner, Efficiency Location Duct Thermostat Configuration heat pump, eva . cooling) (SEER) attic, etc. R -Value Type (split or package) 7/, SEALED DUCTS and TXVs (or Alternative Measures ❑ Sealed Ducts (all climate zones) (Installer testing and certification and HERS rater field verification required) ❑ TXVs or Commission approved equivalent, readily accessible. (climate zones 2 and 8-15 only) (Installer testing and certification and HERS Rater or field verification required) OR ❑ Alternative to Sealed Ducts and TXVs (see Package C or,D Alternative Package Features for Project Climate Zone) Climate Zone Window SHGC Window U -Factor SEER Heating. WATER HEATING SYSTEMS Energy' External Rated' Tank Factor or Tank Water Heater Distribution Number Input (kW Capacity Recovery Standby' Insulation T e Type in System or Btu/hr(gallons) 'Efficiency Loss % R -Value I. 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 of greater than 75,000 Btu/hr), list Rated Input, Recovery Efficiency and Standby Loss. For instantaneous gas water heaters, list rated input and recovery efficiencies. SPECIAL FEATURES (add extra sheets if necessary). Package.C`and D: TXVs or Commission approved equivalent, Sealed Ducts, Radiant Barriers (see installation requirements for radiant barriers in Section 8.13 of the 1999 Residential Manual). Package C: thermal mass (thermal mass type, covering, thickness, and description). January 5, 2001 CERTIFICATE OF COMPLIANCE: RESIDENTIAL .(Page 3 of 3). ..CF -IR COMPLIANCE STATEMENT This certificate of compliance lists the building features and performance specifications needed to comply with Title 24, Parts 1 and 6 of the California Code of Regulations, and the administrative regulations to implement them. This certificate has been signed by the individual with overall design responsibility. The undersigned recognize that compliance using duct sealing and TXVs (or Commission approved equivalent) requires installer testing and certification and field verification by an approved HERS rater. Designer or Owner (per Business and Professions Code) Documentation Author Name: Title/Firm: Address: Telephone: Lic. M (signature) (date) Enforcement Agency Name: Title: Agency: R Telephone: (signature / stamp) (date) Name: Title/Firm: Address: Telephone: (signature) January 5, 2001 (date) CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTING (Part 1) CF4R Project Title Date Project Address Builder Name Builder Contact Telephone Plan Number HERS Rater Telephone Sample Group Number Certifying Signature Date Sample House Number Firm: HERS Provider: Street Address: City/State/Zip: Copies to: Builder, HERS Provider HERS RATER COMPLIANCE STATEMENT The house was: ❑ Tested ❑ Approved as part of sample testing, but was not tested As the HERS rater providing diagnostic testing and field verification, I certify that the houses identified on this form comply with the diagnostic tested compliance requirements as checked on this form. ❑ Distribution system is fully ducted (i.e., does not use building cavities as plenums or platform .returns in lieu of ducts) ❑ Where cloth backed, rubber adhesive duct tape is installed, mastic and drawbands are used in combination with cloth backed, rubber adhesive duct tape to seal leaks at duct connections. ❑ MINIMUM REQUIREMENTS FOR DUCT LEAKAGE REDUCTION COMPLIANCE -CREDIT Duct Diagnostic Leakage Testing Results (Maximum 6% Duct Leakage) Measured Duct Pressurization Test Results (CFM @ 25 Pa) values Test Leakage Flow in CFM If fan flow is calculated as 400cfm/ton x number of tons enter calculated value here If fan flow is measured enter measured value here Leakage Percentage (100 x Test Leakage/Fan Flow) _ Check Box for Pass or Fail (Pass=6% or less) _ ❑. THERMOSTATIC EXPANSION VALVE (TXV) or Commission approved equivalent ❑ ❑ Pass Fail ❑ Yes ❑ No Thermostatic Expansion Valve (or Commission approved equivalent) is installed and Access is provided for inspection ❑ ❑ Yes is a pass, Pass Fail ❑ "MINIMUM REQUIREMENTS FOR DUCT DESIGN COMPLIANCE CREDIT 1. ❑ Yes ❑ No ACCA Manual D Design requirements have been met (rater has verified that actual installation matches values in CF -1 R and design on plan. 2. ❑ Yes ❑ No TXV is installed or Fan flow has been verified. If no TXV, verified fan flow matches design from CF -1 R. Measured Fan Flow = _ ❑ ❑ Yes for both 1 and 2 is a Pass Pass Fail January 5, 2001 'CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTING (Part 2) CF4R Project Title Plan Number Date Sample Group Number Sample House Number ❑ MINIMUM REQUIREMENTS FOR DUCT IN CONDITIONED SPACE COMPLIANCE CREDIT Field Verification Results ❑ Yes ❑ No Duct in conditioned space criteria matches CF -1 R ❑ ❑ Yes is a Pass Pass Fail ❑ MINIMUM REQUIREMENTS FOR REDUCED DUCT SURFACE AREA COMPLIANCE CREDIT Measured duct exterior surface area in the following unconditioned duct locations (square feet): Attics Crawlspaces Basements Other (e.g., garages, etc.) ❑ Yes ❑ No Duct surface area matches CF -1 R? ❑ ❑ Yes is a Pass Pass Fail January 4, 2001 INSTALLATION CERTIFICATE. (Page 5 of 8) ' CF -6R Site AddressPermit Number BUILDING ENVELOPE-LEAKAGE'DIAGNOSTICS ❑ ENVELOPE SEALING INFILTRATION REDUCTION ❑ Diagnostic Testing Results Building Envelope Leakage (CFM @ .50 Pa) as measured by Rater 1. Is measured envelope leakage. less than or equal to,the required level Yes No from. CF -1 R7 2. ❑ ❑ _. is Mechanical Ventilation shown as.eequired on.the CF -1 R? Yes No 2a. ❑ ❑ If Mechanical Ventilation is required on the CF -,1 R'(Yes in line 2), has Yes No _ . it been installed? 2b. Check this box yes if'mechanical ventilation is required. (Yes in line 2) Yes No and ventilation fan watts*are'no greater than shown on CF -1R. Measured Watts = 3. ❑ Check this box yes if measured building infiltration (CFM. @ 50 Pa).is Yes No greater than the CFM @.50 values shown for an SLA of. 1..5 on CF -1 R. (If this box is checked no, mechanical ventilation is required.) 4. Check this box yes if measured:building infiltration (CFM:@ 50 Pa) is Yes No less than the CFM @ 50 values shown for'an SLA of 1.5 on CF -1 R, mechanical ventilation is installed and house pressure is greater than minus 5 Pascal with all exhaust fans operating. Pass if:. Pass.' Fail a. Yes in line 1 and line 3, or b. Yes in line 1 and line2, 2a, and 2b, or c. Yes in line 1 and Yes in line 4. - Otherwise fail. 1, the undersigned, verify that the building envelope leakage meets the requirements clai .med for building leakage reduction below default assumptions as used for compliance on the CF71R. This is to ceitify 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 sub -contractors certifying that diagnostic.testing and installation meet the requirements for.compliance credit.]; Test Performed Signature "Date COPY TO: Building Department HERS Provider (if applicable) Building Owner at Occupancy Testing Subcontractor. (Co. Name) OR General Contractor (Co. Name) . January 4, 2001 CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTING (Part 3) CF4R Project Title Plan Number Date Sample Group Number Sample House Number ❑ MINIMUM REQUIREMENTS FOR INFILTRATION REDUCTION COMPLIANCE CREDIT Diagnostic Testing Results Building Envelope Leakage (CFM @ 50 Pa) as measured by Rater 1. ❑ ❑ Is measured envelope leakage less than or equal. to the required Yes No level from CF -1 R? 2. ❑ ❑ Is Mechanical Ventilation shown as required on the CF -1 R? Yes No 2a. ❑ ❑ If Mechanical Ventilation is required .on the CF -1 R (Yes in line 2), Yes No has it been installed? 26. ❑ Check this box yes if mechanical ventilation is required (Yes in line Yes No 2) and ventilation fan watts are no greater than shown on CF - 1 R. 3. ❑ ❑ Check this box yes if measured building infiltration (CFM @ 50 Pa) Yes No is greater than the CFM @ 50 values. shown for an SLA of 1.5 on CF -IR (If this box is checked no, mechanical ventilation is required.). - 4. - ❑ ❑ Check this box yes if measured building infiltration (CFM @ 50 Pa) Yes No is less than the CFM @ 50 values shown for an SLA.of 1.5'on CF -1R, mechanical ventilation is installed and house pressure -is • greater than minus 5 Pascal with all exhaust fans operating. Pass if: Pass Fail a. Yes in line 1 and line 3, or b. Yes in line 1 and line2, 2a, and 2b, or C. Yes in line 1 and Yes in line 4. Otherwise fail. January 4, 2001 INSTALLATION CERTIFICATE (Page 2. of 8) CF -6R Site Address Permit Number FENESTRATION/GLAZING: Total Quantity Product Product of Like Exterior Shading U -Factor' (< SHGC' (<_ # of Product Square Device or Comments/Location/ _ _Manufacturer/Brand Name CF -1 R value) 2 CF -IR value)Z Panes Motional) Feet Overhane Special Features (GROUP LIKE PRODUCTS) 2. _ 3. _ 4. _ 5. 6 — 6. — 8. _ 9. _ 10. 11. — 12. _ 13. 14. —_ 15. ' Manufactured fenestration products use the values from the product label. Field fabricated fenestration products use the _ default values from Section 116 of the Energy Efficiency Standards. Z Installed U -Factor must be less than or equal to values from CF -1 R. 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 CFAR. Alternatively, installed weighted average U -Factors for the total fenestration area are less than or equal to values from CF -1R. 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 (if applicable) Item #s (if applicable) Item #s (if applicable) Signature, Date Installing Subcontractor (Co. Name) OR General Contractor (Co. Name) OR Owner OR Window Distributor Signature, Date Installing Subcontractor (Co. Name) OR General Contractor (Co. Name) OR Owner OR Window Distributor Signature, Date COPY TO: Building Department HERS Provider (if applicable) Building Owner -at Occupancy January 4, 2001 Installing Subcontractor (Co. Name) OR General Contractor (Co. Name) OR Owner OR Window Distributor INSTALLATION CERTIFICATE (Page 1 of 8) 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; however, use of this form to provide the information is. optional.) 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(b). HVAC SYSTEMS: Heating Equipment Equip. # of Efficiency Duct Duct or Heating Heating Type (pkg. CEC Certified Mfr Name Identical (AFUE, etc.)' Location Piping Load Capacity heat pump) and Model Number Systems f>_CF-I R'valuel (attic. etc.) R -value (RftAr) (Btu/hr) Cooling Equipment Equip. CEC Certified Compressor # of Efficiency Duct Cooling Cooling Type (pkg. Unit Mfr Name and Identical '(SEER, etc.)) Location Duct Load Capacity heat numn) Model Number Svstems I>CF-1 R valuel (attic. etc.) R-valuc (Btu/hr) (Btu/hr) 1. > reads greater than or equal to. 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 -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. Signature, Date Installing.Subcontractor (Co. Name) OR General Contractor (Co. Name) OR Owner WATER HEATING SYSTEMS: Distribution If Recir- # of Rated' Tank Effi- External Heater . CEC Certified Mfr Type (Std,. culation, Identical Input (kW Volume ciency' Standby' Insulation Type. Name & Model Number Point -of -Use) Control Type Systems ' of Btu/hr) (gallons) (EF, RE) Loss (%) R -value' 2 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. For large gas storage water heaters (rated input of greater than 75,000 Btuthr), list Recovery Efficiency, Standby Loss and Rated Input. For instantaneous gas water heaters, list Recovery Efficiency and Rated Input. 3. R-12 external insulation is mandatory for storage water heaters with an energy factor of less than 0.58. Faucets & Shower Heads: All faucets and showerheads installed are certified to the Commission, pursuant to Title 24, Part 6, Section 111. 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 Regulations or Part 6), where applicable. Signature, Date . Installing Subcontractor (Co. Name) OR General Contractor (Co. Name) OR Owner COPY TO: Building Department HERS Provider (if applicable) Building Owner at Occupancy January 4, 2001 INSTALLATION CERTIFICATE (Page 3 of 8) CF -6R Site Address Permit Number DUCT LEAKAGE AND DESIGN. DIAGNOSTICS ❑ DUCT LEAKAGE REDUCTION Pressurization Test Results (CFM @ 25 PA) Test Leakage (CFM) Fan Flow If Fan Flow is Calculated as 400 cfm/ton.x number of tons, or as 21.7 x Heating Capacity in Thousands of Btu/hr, enter calculated value here If fan flow is measured, enter measured value here Leakage Fraction = Test Leakage/(Measured or Calculated Fan Flow) _ Pass if leakage fraction _< 0.06 ❑ ❑ Pass Fail ❑ For AEROSOL TYPE SEALANTS ONLY - The following diagnostic testing was completed: Duct Fan Pressurization at rough -in measured leakage (CFM) CHECK AFTER FIMSHING WALL: ❑ Yes ❑ No ❑ Pressure pan test or House pressurization test ❑ Yes ❑ No ❑ Visual Inspection of Duct Connections 13' ❑ Pass Fail ❑ THERMOSTATIC EXPANSION VALVE (TXV) ❑ Yes ❑ No Thermostatic Expansion Valve (or Commission approved equivalent) is installed and Access is provided for in ❑ ❑ Yes is a pass Pass Fail ❑ DUCT DESIGN 1 ❑ Yes .❑ No ACCA Manual D Design calculations have been completed, Duct Design is on the plans and duct installation matches plans. 2• ❑ Yes ❑ No TXV is installed or Fan flow has been verified. If no TXV, verified fan flow matches design from CF -I R. Measured Fan Flow = Yes for both I and 2 is a Pass Pass Fail ❑ I, the undersigned, verify that the above diagnostic test results'and the work i performed associated with the tests) 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 sub -contractors certifying that diagnostic testing and installation meet the requirements for compliance credit.] Tests Performed O Signature, Date COPY TO: Building Department HERS Provider (if applicable) Building Owner at Occupancy January 4, 2001 Installing Subcontractor (Co. Name) OR General Contractor (Co. Name) INSTALLATION CERTIFICATE (Page 4 of 8) CF -6R Site Address Permit Number DUCT LOCATION AND AREA REDUCTION DIAGNOSTICS ❑ DUCT IN CONDITIONED SPACE ❑ Yes ❑ No Duct in conditioned space criteria matches CF -1 R Yes is a Pass Pass Fail ❑ REDUCED DUCT SURFACE AREA Measured duct exterior surface area in the following unconditioned duct locations (square feet): Attics Crawlspaces Basements Other (e.g., garages, etc.) ❑ Yes ❑ No Duct surface area matches CF -1 R? ❑ ❑ Yes is a Pass Pass Fail ❑ I, the undersigned, verify that the duct surface area and duct locations claimed for duct surface area reductions and duct location improvements beyond those covered by default assumptions match those on the plans. [The builder shall provide the HERS provider a copy of the CF -6R signed by the builder employees or sub -contractors certifying that diagnostic testing and installation meet the requirements for compliance credit.] Tests Signature, Date Performed COPY TO: Building Department HERS Provider (if applicable) Building Owner at Occupancy January 4, 2001 j Installing Subcontractor (Co: Name) OR General Contractor (Co. Name) MANDATORY MEASURES CHECKLIST: RESIDENTIAL (Page 2 of 2)_ MF -1R Note: Lowrise residential buildings subject to the Standards must contain these measures regardless of the compliance approach used. Items marked with an asterisk (•) may be superseded by more -stringent compliance requirements listed on the Certificate of Compliance. When this checklist is incorporated into the permit documents, the features noted shall be considered by all parties as minimum component performance specifications for the mandatory. measures whether they are shown elsewhere in the documents or on this checklist only. Instructions: Check or initial applicable boxes when completed or enter N/A if not applicable. DESCRIPTION DESIGNER ENFORCEMENT Space Conditioning, Water Heating. and Plumbing System Measures: (continued) • § 150(m): Ducts and Fans 1. All ducts and plenums installed, sealed and insulated to meet the requirement of the 1998 CMC Sections 601, 603, 604, and Standard 6-3; ducts insulated to a minimum installed level of R4.2 or enclosed entirely . in conditioned.space. Openings shall be sealed with mastic, tape, aerosol sealant, or other duct -closure system that meets the applicable requirements of UL 181, UL 181 A, or UL 181 B. If mastic or tape is used to seal openings greater than 1/4 inch, the combination of mastic and'either mesh or tape shall be used. Building cavities shall not be used for conveying conditioned air. Joints and scams of duct systems and their components shall not be sealed with cloth back rubber adhesive duct tapes unless such tape is used in combination with mastic and drawbands. 2. Exhaust fan.systems have back draft or automatic dampers: 3. Gravity ventilating systems serving conditioned space have either automatic or readily accessible, manually operated dampers. § 114: Pool and Spa Heating Systems and Equipment. 1. System is certified with 78% thermal efficiency, on-off switch, weatherproof operating instructions, no electric resistance heating and no pilot light. 2. System is installed. with: a. At least 36" of pipe between filter and heater for future solar heating. b. Cover for outdoor pools or outdoor spas. 3. Pool system has directional inlets and a circulation pump time switch. § 115: Gas-fired central furnaces, pool heaters, spa heaters or household cooking appliances have no continuously burning pilot light. (Exception: tion: Non -electrical cooking appliances with pilot < 150 Btu/hr Lighting Measures: § 150(k) I .:.Luminaires for general lighting in kitchens shall have lamps with an efficacy of 40 lumens/watt or greater for general lighting in kitchens. This general lighting shall be controlled by a switch on a readily accessible lighting control panel at an entrance to the kitchen. § 150(k)2.: Rooms with a shower or bathtub must have either at least one luminaire with lamps with an efficacy of 40 lumens/wan or greater switched at the entrance to the room or one of the alternatives to this requirement allowed in $150 2.; and recessed ceiling fixtures are IC insulation cover approved. January 4, 2001 MANDATORY MEASURES CHECKLIST: RESIDENTIAL (Page.l of 2) MF -IR Note: Lowrise residential buildings subject to the Standards must contain these measures regardless of the compliance approach used. Items marked with an asterisk (•) may be superseded by more stringent compliance requirements listed on the Certificate of Compliance. When this checklist is incorporated into the permit documents, the features noted shall be considered by all parties as minimum component performance specifications for the mandatory measures whether they are shown elsewhere in the documents or on this checklist only. Instructions: Check or initial applicable boxes when completed or enter N/A if not applicable. DESCRIPTION DESIGNER ENFORCEMENT Building Envelope Measures: • §150(a): Minimum R-19 ceiling insulation. §I50(b): Loose fill insulation manufacturer's labeled R -Value. • §150(c): Minimum R-13 wall insulation in wood framed walls or equivalent U -Factor in metal frame walls does not apply to exterior mass walls). • §150(d): Minimum R-13 raised floor insulation in flamed floors. § 1500) : Slab edge insulation - water absorption rate no greater than 0.3%, water vapor transmission rate no greater than 2.0 enn/inch. §118: Insulation specified or installed meets insulation quality standards. Indicate type and forth. § 116-17: Fenestration Products, Exterior Doors, and Infiltration/Exfiltration Controls I. Doors and windows between conditioned and unconditioned spaces designed to limit air leakage. 2. Fenestration products (except field -fabricated) have label with certified U -Factor, certified Solar Heat Gain Coefficient (SHGC), and infiltration certification. 3. Exterior doors and windows weatherstripped; all joints and penetrations caulked and sealed. § 150(g): Vapor barriers mandatory in Climate Zones 14 and 16 only. § 150(f): Special infiltration barrier installed to comply with,§ 151 meets Commission quality standards. § 150(e): Installation of Fireplaces, Decorative Gas Appliances and Gas Logs. 1. Masonry and factory -built fireplaces have: ' a. Closeable metal or glass door b. Outside air intake with damper and control c. Flue damper and control 2. No continuous burning gas pilot lights allowed. Space Conditioning, Water Heating and Plumbing System Measures: § 110-§ 113: HVAC equipment, water heaters, showerheads and faucets certified by the Commission. § 150(h): Heating and/or cooling loads calculated in accordance with ASHRAE, SMACNA or ACCA. § 150(i): Setback thermostat on all applicable heating and/or cooling systems. § 1500): Pipe and tank insulation 1. Storage gas water heaters rated with an Energy Factor less than 0.58 must be externally wrapped with insulation having an installed thermal resistance of R-12 or greater. 2. First 5 feet of pipes closest to water heater tank, non -recirculating systems, insulated (R4 or greater) 3. Back-up tanks for solar system, unfired storage tanks, or other indirect hot water tanks have R-12 external insulation or R-16 combined intemal/extemal insulation. 4. All buried or exposed piping insulated in recirculating sections of hot water systems. 5. Cooling system piping below 55° F insulated. 6. Piping insulated between heating source and indirect hot water tank. January 4, 2001 INSTALLATION CERTIFICATE (Page 5 of 8) CF -6R Site Address Permit Number BUILDING ENVELOPE LEAKAGE DIAGNOSTICS '❑ ENVELOPE SEALING INFILTRATION REDUCTION Diagnostic Testing Results Building Envelope Leakage (CFM @.50 Pa) as measured by Rater 1. . ❑ ❑ Yes No 2. ❑ .❑ Yes No 2a. ❑ ❑ Yes No 2b. ❑ ❑ Yes No 3 ❑ ❑ Yes No Is measured envelope leakage less than or equal to the required level from. CF -1 R? Is Mechanical Ventilation shown as required on the CF -1 R? If Mechanical Ventilation is required on the CF -1R (Yes in line 2), has it been installed? Check this box yes if mechanical ventilation is required (Yes in line 2) and ventilation fan watts are no greater than shown on CF -1 R. Measured Watts = Check this box yes if measured building infiltration (CFM @ 50 Pa), is 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.) 4. ❑ ❑ Check this box yes if measured building infiltration (CFM @ 50 Pa) is Yes No less than the CFM @ 50 values shown for an SLA of 1.5 on CF -1 R, 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 1 and Yes in line 4. Otherwise fail. ❑ . ❑ Pass Fail ❑ •I, 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 CFAR. 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 dopy of the CF -6R signed by the builder employees or sub -contractors certifying that diagnostic testing and installation meet the requirements for compliance credit.) Test Performed Signature Date Testing Subcontractor (Co. Name) OR General Contractor (Co. Name) COPY TO: Building Department HERS Provider (if applicable) Building Owner at Occupancy January 4, 2001 INSTALLATION CERTIFICATE (Page 6 of 8) CF -6R Site Address Permit Number The following is an explanation of many of the input values required on this form: HVAC SYSTEMS Heating Eouinment Tvne mutt he nne of the fnllAurino- Furnace: Gas (including Liquefied Petroleum Gases) or oil -fired central furnace & space heater Boiler: Gas or oil -fired boiler PckgHeatPump: Packaged central heat pump SplitHeatPump: Split central heat pump RoomHeatPump: Room heat pump LgPkgHeatPump: Large packaged heat pump (>_ 65,000 Btu/hr output) Electric: Electric resistance heating (fixed HSPF = 3.413); radiant electric resistance (fixed HSPF = 3.55) CombinedHydro: Reference water heater under water heating systems below CEC Certified Manufacturer Name & Model Number from applicable Commission approved appliance directory. # of Identical Systems is for those systems with the same efficiency, duct location, duct R -value and capacity. Efficiency from applicable Commission certified appliance directory.' Duct (or Piping) Location is attic, crawl space, CVC crawl space, conditioned space, unconditioned space or none. Duct (or Piping) R -Value from Directory of Certified Insulation Materials and/or manufacturer's data. Heating/Cooling Load refer to Commission approved load calculation procedure. Heating/Cooling Capacity from the applicable Commission certified appliance directory. Note: location elevations over 2,000 ft above sea level require a derating of output capacity (refer to manufacturer's literature). Conlin4 Fnuinment Tvne mnct hr nne of the fnllmarino• SplitAirCond: Split system air conditioner PckgAirCond: Packaged air conditioner Split Heat Pump: Split system heat pump PckgHeatPump: Packaged heat pump RoomHeatPump: Room heat pump LgPkgHeatPump: Large packaged heat pump (>_ 65,000 Btu/hr output). Substitute EER for SEER when SEER is not available RoomAirCond: Room air conditioner. Minimum SEER varies* LgPkgAirCond: Large packaged air conditioner (>_ 65,000 Btu/hr output). Substitute EER for SEER when SEER is not available EvapDirect: Direct evaporative cooling system. For compliance calculation purposes, fixed values: SEER = 11.0; duct location = attic; duct insulation R -value = 4.2 EvapIndirect: Indirect evaporative cooling system. For compliance calculation purposes, fixed values: SEER = 13.0; duct location = attic; duct insulation R -value = 4.2 Heid w nucigy wiiumsswn puoncanon Appuanee rjiicieney Kegutations, r4uu-92-m January 4, 2001 INSTALLATION CERTIFICATE (Page 7 of 8) CF -6R Site Address Permit Number The following is an explanation of many of the input values required on this form: WATER HEATING SYSTEMS Distribution Svstems Refer to Residential Manual for more details - Standard: Standard - Supply pressure based system, no pumps Pipe Insulation: Pipe Insulation on al3/4-inch pipes POU/HWR: Point of Use/Hot Water Recovery System Recirc/NoControl: Recirculation loop with no controls Recirc/Timer: 'Recirculation loop with a timer Recirc/Temp: Recirculation loop with temperature control Recirc/Time+Temp: Recirculation loop with a timer and temperature control Recirc/Demand: Recirculation loop with demand control Water Heater Type Storage Gas, Oil or Electric Heat Pump Instantaneous Gas .Instantaneous Electric Large.Storage Gas Indirect Gas (Boiler) FENESTRATION/GLAZING Fenestration: Information Needed Energy Factor Recovery Efficiency Standby Loss Rated Input Yes No No No Yes No No No No Yes No No Yes No No No No Yes Yes Yes No Yes (AFUE) No Yes Fenestration: Windows, sliding glass doors, French doors, skylights, garden windows, and any door with more than one square foot of glass Operator Type: Slider, hinged, fixed U -Factor: Installed U -Factor must be less than or equal to value from CF -1R OR Installed weighted. average U -Factor for the total fenestration area is less than orequal to value from CF -1R SHGC: Installed SHGC must be less than or equal to value from CF -1R OR Installed weighted SHGC for the total fenestration area is less than or equal to value from CF -IR OR An interior shading device, overhang, or exterior shading device is installed consistent with the CF -1R Shading Device: Include when the building complied using an exterior shading device: woven sunscreen, louvered sunscreen, low sun angle sunscreen, roll -down awning, roll -down blinds or slats (do not list bug screen), or an overhang (include depth in feet January 4, 2001 INSTALLATION CERTIFICATE (Page 8 of 8) CF -6R Site Address Permit Number The following is an explanation of many of the input values required on the Diagnostic portion of this form (page 3 of 6): TYPE OF CREDIT Refer to Residential Manual Chapters 4 and 5 for more details: , Reduced Duct Surface Area: Calculated as the outside area of the duct. Areas must be measured and verified by a HERS rater. . Improved Duct Location: Supply duct located in other than attic, as verified by location of registers (does not require HERS rater verification). Catastrophic Leakage: Pressure pan test readings must be less than 1.5 Pascal at a house pressure of 25 Pascal. TXV (or Commission Access cover required to facilitate verification. Eligibility criteria for approved equivalent): Commission approved equivalent, if applicable, is required.to be met. Infiltration Reduction: Infiltration is measured without mechanical ventilation operating. Mechanical ventilation is required for very tight house construction when credits for infiltration reduction using diagnostic testing are being used for achieving compliance. These very tight houses are defined as those with SLA of less than I.S. The compliance documentation (CF -1R) will contain the measured CFM target value from a blower door test at 50 Pascal pressure difference that represents this SLA of 1.5. Mechanical ventilation is also . required if the builder chooses to design the. building to use mechanical ventilation and claims a credit for infiltration below an SLA of 3.0. The compliance documentation (CF -1R) will contain the measured CFM target value that represents this 3.0 SLA. If the builder claims credit in a design for infiltration reduction that is at an.SLA of 3.0 or higher, and the actual measured SLA is 1.5 or greater, then mechanical ventilation is not required. If the SLA in this case were below 1.5, then mitigation (such as mechanical ventilation) would be required. January 4, 2001