08-0421 (MECH)4 P.O. BOX 1504 .
78-495 CALLE TAMPICO
LA QUINTA,; CALIFORNIA 92253 BUILDING & SAFETY. DEPARTMENT
BUILDING PERMIT
Application Number:
08-00000421 _. .
Property Address:
5_ AVENIDA—NAVARR•''
. C1
APN:
_5,375
774-174-013-1 -000000-
Application description:
MECHANICAL
Property Zoning:
COVE RESIDENTIAL
Application valuation:
9100
Applicant:
Architect or Engineer:
--------------------------------------------------
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 Cass: C20 -C36 ^, LicenseNo.: 481393
Dater.Contractor:
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).:
(_ 1 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.). - -
' ( ) 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:
DENOVI MARJORIE E
53-755 AVENIDA NAVARRO
STANTON., CA 90680
(760) 771-2554
Contractor: -
MAPLE LEAF PLBG
P.O. BOX 3653
PALM DESERT, CA�
(760)346-6758
Lic. No_ 481393
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760).7'77-7153
61 r4aA . .O 7 �n(�� U
C� �� F It A Q�►n►Ur
Date: ' ' 3/07/08
----------------•-------- ------ ----=- - - - - —
WORKER'S COMPENSATION DECLARATION
I 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 ENDURANCE REINS Policy Number WEN1000915-02
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
^1/31700 of the Lab I he with comply with those provisions.
Date: / 16 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 lawsrelating to building construction, and hereby authorize representatives'
of this cao1111VV.��ntNN tApo�e�nter upon the above-mentioned .dr—ope'rN for ir]ep n purposes.
Date _.) 1. / 1 Ua- Signature (Applicant or Agent):
Application Number . . . . _ 08-00000421
Permit MECHANICAL
Additional des c .
Permit. Fee`••:... 33.00;
Plan Check Fee
00
Issue Date -.r
Valuation
0
Expiration Date 9/03/08
Qty Unit Charge Per
Extension
' BASE
FEE
15.00
1.00 9.0.000 EA MECH
FURNACE <=100K
9.00--:__-----
1.UU':` 9.0000 BA MECH
B/C.<=3HP/100K BTU
9.00 .
Special Notes and Comments
A/-C.SPLIT HEAT -PUMP CHANGE OUT
Fee -summary Charged
Paid Credited-
Due
Permit Fee Total- 33.00
.00 .00
33.00
Plan Check Total .00
.00 .00
.00
Grand Total 33.00
.00 .00
33.00
q
LQPERMIT --
Bin #
City of La Quinta.
Building U Safety Division
P.O. Box 1504, 78-495 Calle Tampico
La Quinta, CA 92253- (760) 777-701
Building Permit Application and Tracking Sheet
Permitfl
�•`
Project Address:62-7-5s
Owner's Name: p v✓ �� v�
A. P. Number:Address:
* 15-3 —?SSH d l� GU✓U
Legal Description;
Contractor:yZ Ib
City, ST, Zip:
Telephone:
Address: U O R^ 3
Project Description:
City, ST, Zip: �� 1 w— U ey�� - Q 'Z 240
Telephone:( 7(o6) 3y !07
�P
State Lic. # : t•} 19 3
City Lic. #:
Arch., Engr., Designer:
Address:
City, ST, Zip:
Telephone:
State Lic. #:
Name of Contact Person:
Construction Type: Occupancy:
Project type (circle one): New Add'n Alter Repair Demo
Sq. Ft::
# Stories:
#Units:
Telephone # of. Contact Person:
P �% 2 ^ %vj
Gc
Estimated Value of Project: (d �
APPLICANT : DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'd
Rec'd
TRACKING
PERMIT FEES
Plan Sets
Plan Check submitted
Item
Amount
Structural Calcs.
Reviewed, ready for'corrections
Plan Check Deposit
Truss Calcs.
Called Contact Person
Plan Checx Balance
Energy Calcs.
Plans picked up _
Construction
Flood plain plan.
Plans resubmitted
MechanicF!
Grading:plan
2nd Review, ready. for
Electrical
Subcontactor List
Called Contact Person
Plumbing
Grant Deed
Plans picked up
S.M.I.
H.O.A. Approval '
Plans resubmitted
Grading
IN HOUSE:-
'^' Review, ready for corrections/issue
Developer Impact Fee
Planning Approval
CalledContact Person
A.I.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees
Total Permit Fees
ZIP
ro - - (j
.0
PRINTINGSOLUTIONS (760) 568-5440 --1
MAPLE LEAF.. PLUMIBING,-
HEATING AND AIR CONDITIONING, :INC.
P.O. Box 3653
PALM DESERT, CALIFORNIA 92261
.(760) 346-6758
Lic.'#481393
a
21— —;— 3
NAME . -
&Vj V.I.) 7553168
RROPOSAL AND
ACCEPTANCE. -
[!]-farts warranty 05-L
Ertompresso'r warranty
I —-
0 Heat exchanger warranty
6<abor warranty
0 modifications Of Supply Plenum' 0 Return Plenum.
0 Fabricate New Supply Plenum 0 Return Plenum
0 New Supply Register, 0 Bar 0 Curved Blade Qty._,_.
0 New Return Grille O'Filter Grille 0 Non Filter
Hook Up to Existing. Duct Work
0 Disconnect Box [I . 30 Amp. 0 60 Amp..
0 Other
rr—Use Existing
•
0 High Efficient Air Filter
0 -Humidifier
G�Ihermostat
0 Attic Safety Pan .
0 Condensate Pump
11 U.V. Lights
NOTICE TO OWNER: Contractors are required by law to be licensed and regulated by the
contractors'
stale license board. Any questions concerning a contractor may be referred to the
registrar
e istrar o the board whose address is: Contractors, State License Board, 9821 Business Park
Dr� Sacramento, CA 95827
Proposal does not cover:
Customer Signature:
Maple Leaf Signature.
All material is guaranteed to be as specified. All work to be completed'
manner accojdi�q,to.s in a workman -like
standard practices. Any alteration or deviation from above soecifications
law=
0 Condensate 11 Primary
Secondary [I Copper
11PVC OAtiic Safety Pan, Cost_
❑ Refrigerant Lineset
0 Vent Pipe Size: 0 Single 0 Double
Line 0 Flex 0 Pipe To From
se Existing
•
vr-do'n'denlser Pad 11 Crane -0 Large Crane
O -A-11 work performed in'a heat and professional manner. Job
site will be clean at the conclusion of each day's work and
all debris. removed from the premises.
0 Other
0 Vibration Pads [I ISO pad 0 Ball Suspension
0 Use Existing Platform
0 Build Roof Curb OSheet Metal Cap
0 Modify Existing Platform
Your New System Price is .............
Options.... . . ...................
-State Required Duct Testing and P-Irmits ...........
------
96
Rebates .............. .......... ; ..................
. ..........
Factory Rebates ............................. . .............
Other ....... ............. ............ . ..................
................................... ................
. ..................
........................................... Q .................................
Total .............. ..................
Woo
Payment T6rms: 0% down balance upon
completion
.,XCredit Card - E]Check
Balance'due upon completion
Customer Sid.
-��
CI✓RTITICA TE OI+ COMPLIA.NCE:, RE' SIDLNTxA-L (Page's of 4) CIF -IR
01 [Nao
-Project Title n—.ild
a� lll4�s��yProject AddressDocumentation AuthorTelephone Compliance Method (Prescriptive)
Cii to Zone Fa,Corcta ent
Agcocy Me Only.
1 D Alternative Component Package Method (check one
C D D (Alternative) .
Package C and Package D choices require HERS'rater field verification and/or f
For Package D Alternative see A agnostic testing (ice CF -IR page 3).'.
ppegdix.B Tabie l5l-CFootnotes 1-14
GENERAL INFORMAITON
Total Conditioned. Floor Arca CFA
( ) 82 . •Average Ceiling Height ti
Maximutit Allowed Wmt.Facing Fenestration' products Per Table 151-Bor TSI -C----(5% X CFA)
Maximum Allowed Total Fenestration Products Per Table 1514$ or I5I-C (p�/ X CFA) ft
✓ 13 Building �- 06r k one or more) Single Famil
Y " Multifamily Addition Alteration
madding fenestration fill out WSAN—Fen stration Maximum Allowed Area.Woriksheet and
for Additions and &3.3 .for. Alterations:). sec Section 83.2 .
Number of stories: t _ Number of Dwelling Units:
Floor rbrt uvtion Types: a Slabi/R.aised leer circle
Front Orientation: ( one o� ��)
Noi1h /South East / est /AII Orientations ('input front orientation in degrees from True
North and circleone).
RADIANT $ARRIER uirtd. in timate zones 4' 8-15
O_ PAOUE SURFACES TNCLUDI�IG OPAOUE DOORS
Component . Asscmb�y U -
Type Wall Frame
Actor for
Rooi; Floor, T ( Joint RoofftRant
'Slab.Ed YPe Cavity Continuous•. .: wood, metal Appendix' farrier
gel . (Wood Insulation Insulation carne and mass Location/Comnfents:
Doors orM IV.. ' Installed . (attics garage,
ani R -Value R=Value. assemblies r Reference . Yes or Tlo '
seal, etc.
1) See Joint Appendix IV in Section 1 V-2, IV.3 and 1V.4; �4hich is the basis for the U -factor criterion U -factors cannot
exceed prescriptive value to show equivalence to R -values:
J
Residential Compliance Forms
.March 2005
CERTIFICATE OF COMPLIANCE; RESIDENTIAL
(Page 2 of
4) CF -IR'
rro�ect Title V� "
.
Date
FENESTRATION PRODUCIS =U -FACTOR AND SHCC
-
❑ FENESTRATION MAXIMUM ALLOWED AREA WORKSHEET WS-4R—must
Additions and Alterations. be incluced.for
New Construction ,
Fenestration
#/'I'ype/Pos.
(Front, Left, Orien-
Exterior.
Rear, Right, talion, Area U -factor
S li
Shading(Overhangs6, 7
t N, S . Wt SHGC
U -factor Souree3 SHCC°
✓box if WS 3R is
Source.'
included
a
"
❑
.❑
El
El
❑.
El
1) Skylights are now included.in West -facing fenestration area if the skylights are tilted to the west or tilted in any direction
when the pitch is less than 1:12: See'§ 15IVPC and in Section
323 of the Residential Manual
2) Enter values' this column are either NFRC Rated value
or from Standards default Table 116A.
3) Indicate source either from NFRC or Table 116A,
4) Enter values in this column from NFRCor from Standards Default Table 116D oradjusted SHC1C from WS -3R
5) Indicate source either from NFRC or Table 11613.
6) Shading Devices are defined in Table 3-3 in the Residential Manual and see WS -3R to calculate Exbrior..Shading devices:
7) See Section 32A in the Residential Manual.
IAVAC SYSTEMS
Heating Equipment Minimum Distri ution.
Type and Capacity
Efficiency: Type and. Location Duct or Piping Thermostat
furnace heat boder etc.. AFL7E or HSP ducts atti etc. R -Value
Configuration
tit or e
Cooling Equipment . Minimum
Type and Capacity Efficiency Duct Location Duct Thermostat
A/C beat unf eva . cooli SEER or EER attic etc. Duct
Configuration
c 1.
slit or e
Residential Compliance Forms
March 2005
CERTIFICATE OF COMPLIANCE; iZESIDENTUL (Page 3 of4) CF -1R
OFProject Title
Date
SEALED DUCTS and TXVs for Alternative Measures)
A signed CF -411 Form must be provided to the building department for each home for which the following. are
r uired.
Sealed Ducts all climate zones Installer testingand certification and HERS rater field verWiication uired:
TXVs, readily
'accessible (climate zones 2 and 8-15 only)
(Installer testin and certification and HERS Rater field verification uired.
E3 Refrigerant Charge (climate zones 2 and 8-15 only).(InsUdler testing and certification and HERS Rater field
verification required.)
OR
[7 ="ect
Sealed Ducts and Refrigerant e
te Zone in the RM ndix B T j� l s Footnotes go l D Alternative Package Features for
OR.
For additions and alterations, duct systems that are not documented to. have been previously
O sealed as confirmed through field verification and di
stic testing in acco
Residential, ACM Manual and duct systems with moan 40. linear f rdance in -unconditioned
procedures
�u� in the
shall meet the r uirements of Section '150 m and duct insulation r uvements of P e D.
WATER HEATING SYSTEMS
:OldCheck box if system meets criteria of a "Standard" system. Standard system is one gas-fired v-ater• heater per
welling unit If thewater heater isa storage type, 50'gallons is the maximum.capacity and recirculation notallowedsystem is
Greek box when using -Preapproved Alternative Wales Heating table, Table 5-4 in -Chapter 5 in the.Residential
# . Manual. No water heatin calculations are. .
equifedand the stem corn lies automaticall .
Check box if system does not meet criteria of "Standard" system, and does not eo l with the Pr roved
D Alternative Water Heating.table. In this case, the Performance Method must be used and must -ie 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
S stems servin sin le dwellin .units
Rated Energy Tank'
Water:Heater Ditibier.Input'Tank Factor or.External
a in. stem. (kW or Capacity Thermal Standby' Insulation
Ba►/hr loos Efficien Loss % R -Value .
S stein serving multi le dwelliri units.
Rated Energy Tank
Water Heater Distribution Number Input' • Tank Factor' or External \
e in .stem. (kW.,r Capacity Thermal Standby' Insulation
allons Effcien Loss /° R -Value
1. For small gas. ;to rage water heaters (rated inputs .of les'than.or equal to 75,000 Btu/lv), electric resistance, and heat
pump water heaters, list Energy Factor.. For large gas storage water -heaters (rated input of greaterthan 75,000
W11140, list Rated Input, Recovery Efficiency, Thermal Efficiency and Standby Loss. For instantaieous gas water
1
'boaters, list Rated Input and Thermal Efficiencies.
Pipe Insulation (kitchen lines >_ 3/4 inches) All hot water Pipes from the heating source to the kitchen 5bctums that are' 3/
inches, or greater in diameter shall be thermally insulated: specified by Section 150 (j) 2 A or 150 (j) 2 B
Residential Compliance Forms
March 2005
CERTIFICATE OF COMPLIANCE: RESIDENTIAL
(Page 4' of 4 CIF -IR
(P g ) CI' IR
Project Title
Date
' SPECIALFEATURES NOT REQUIRING* HERS VERIFICATION add
Indicate
extra sheets if necessary)
which special features are partof this project. The list below only represents special'. features relevant to the
rescri tive method.
K! Feature
❑ Metal Framed Walls
Re uired Forms if a livable .. Descri tion
❑ Radiant Barriers
CF=1 R-
CF - 1R
❑ Exterior Shades
WS -4R
❑ .. Cool Roof.
N/A; Attach CRRC. Label to
❑ Dedicated Hydronic Heating
. .
Forms.
Performance Calculation
stem
R uired- Attach Run to Forms,
D Combined Hydronic System
Performance Calculation
R uired;.Attach Run.to Forms. -
❑ Gas Cooling
Performance Calculation
❑ Buried Ducts
R uired:
N/A; Indicate on buildin Tans.
❑ Kitchen'Pipe Insulation
See Section 5.62 Distribution
stems in Residential Manual'.
l7' Multiple Water Heaters per
Neel 5-13 or -use
Dwelling Unit
Performance Calculation and
Central Water Heating
El. .. g System
attach Run to Forms.
Performance Calculation and
Servin Multi le Dwellin
�� Non-NAECA Large Water
attach Run to Forms.
❑
Heater
CF -1R
- -❑ Indiceci Water Heater
� Table 5-13 or use
Performance. Calculation and
attach Run to. Forms
❑ .Instantaneous Gas Water Heater
See Table 5-13.or use
Performance Calculation and
.attach Run to Forms
❑ Solar Water HeatingSystem,
Y
See Table 5=13 of use
Performance Calculation and
attach. Run'to .Forms
❑ Wood Stove Boiler
..Performance Calculation and
attach Rurr to Forms
SPECIAL FEATURES RE - II G MRS.RATER VERMCATION
.
Sadd extra sheets if necessary) Indicate to the HERS Rater which credits are part of this projectand need
ver fication.
Duct Sealin
R uired Forms Cif a livable Descri tion
[E]Feature
CF -6R art 4 of 12
CF -6R art 5 of 12
Thermostatic Ex anion Valve ..
CF -:6R art 6 of 12
Residential Compliance Forms
'
March 2005
IJEUVVl
✓ Ef THERMOSTATIC EXPANSION VALVE (TXV)
Procedures for field verification of thermostatic expansion valves are available in RA CM, Appendix Pj
✓ ✓
Access is provided for inspection. The procedure shall
°F
consist of visual verification that theTXV is installed on
✓ - tO Yes ❑ No the system and installation of the specific equipment
4/
❑
shall be verified.
OF
Yes is a ass
Pass Fri!
✓ ® REFRIGERANT CHARGE MEASUREMENT
Verification for Required Refrigerant Charge and Adequate Airflow for Split System Space Cooling Systems without
,rhnrmnctatir Fvnnncinrt vatvPe
Outdoor Unit Serial #
Location
Outdoor Unit Make
Outdoor Unit Model
Cooling Capacity Btu/hr
Date of Verification
Date of Refrigerant Gauge Calibration (must be checked monthly)
Date of Thermocouple Calibration (must be checked monthly)
Standard Charge Measurement Procedure (outdoor air dry-bulb 55'F and aboveh
Procedures for Determining Refrigerant Charge using the Standard Method are available in RACM, Appends RD2.
Note: The system should be installed and charged- in accordance with the manufacturer's specifications before starting this
procedure.
Measured Temperatures
Supply (evaporator leaving) air dry-bulb temperature (Tsupply, db)
°F
Return (evaporator entering) air dry-bnib temperature (Treturn, db)
OF
Return (evaporator entering) air wet -bulb temperature (Tr+eturn, wb)
OF
Evaporator saturation temperature (Tevaporator, sat)
'F
Suction line temperature (Tsuction, db)
OF
Condenser (entering) air dry-bulb temperature (Tcondenser, db)
OF
mperheat Charge Method Calculations for Refii scam Charge
Actual Superheat = Tsuction, db — Tevaporator, sat OF
Target Superheat (from Table RD -2) OF i'
Actual Superheat — Target Superheat (System passes if between -5 and +5*F) "F
Temperature Split Method Calculations for Adequate Airflow,
q—l;t "#4-d ie nnf noroecnry ifAdanLaty Airitnw ~- -dit ie raker
Actual Temperature Split = T return, db Tsupply, db
OF
Target Temperature Split (from Table RD3)
OF
Actual Temperature Split Target Temperature Split (System passel if between -
3°F and +3°F or, upon remeasurement, if between -3*F and -100°F
'F
Residential Compliance Forms April 2005
DetJovl
INSTALLATION CERTIFICATE (Page 4 of 12) CF -6R
Site Address53-vE • i,1 A,-IAr-0, GA Qtj l ATA,. Permit Number
INSTALLER COMPL ANCE STATEMENT FOR DUCT LEAKAGE '
Copies W. Badder Ffflf —Rants, Building owner atOccupancy and I?epatimeat
t INSTAUX11 COMPLIANCE STATEMBNT
The building wag;.,/OTested at Final 0 Tested at Rough -in
INSTALLER VISUAL INSPECTION AT FINAL CONSTRUCTION STAGE:
Remove at least one smmplmly and one return register, and verify tlmt the spaces between theregister bot and the interior
finishing wall are pr opeaiy sealed -
O if the bom rougb4n duct [edmp test was coadnded wkhM an air handle bmalled, the bion points
between the air handler and the supply and retina - plenums to verify that the conaw ion points are properly sealed.
13 Inspect all joints to ensure that no doth backed rubber adhesive dint two is used
DUCT LEAKAGB RUCTION
pranad urpc fir field Fen and &Diio""e0fi. lwdins fair dle"Afterds" p. ,..r ewo .nb.ilwR7.:.. DJ ems A....n...ri.. Di+w 2
NEW
CONSTRUCTION:
Duct Pressurisation Test Results (CFM (a) 25 Pa)
Values
I
Enter -Tested Leakage Flow in CFM:
Fan Flow: Calculated (Nominal: If 9rCDD1mg Ir 0 HeatbW or r 0 Measured
.2
If Fan Flow is Calculated as 400 efnhon x number oftons or as 21.7 c6n/(kBbAw) x Heating
/
1600
Capaft in Thousands of Bhmlhr enter total calculated or meaemmmed fan flow in CM here:
✓ ✓
31
Pass if Leakage Perceaoage5 6% for Final or 5 4% at Rough -in:
O Pass 0 Fail
100 x ine # l /_(Line # 2
ALTERATIONS:
Dad System and/or HVAC Equipment -Out-
4
Enter Tested Leakage Flow m CTM from Pre -Test of Fig Dud S1jAcm Prior to Dant
MFO
-
System Alteration and/or Equipment Change -Out.
5
Enter Tested Leakage Flow in CTM from Final Test of New Dud System or Altered Dud
2�3
Systern for Uund System Alteration and/or Equipment
7
Enter Reduction in Leakage for Altered Duct System
6
3 ine # 4 hl'mru #5)1_ if 'cable
1 O tG
7
Enter Tested Leakage Flow in CFM to Outside (Only ifApplicable)
✓ ✓
8
Entire New Duct System - Pass if Leakage Percentage —< 6% for Final or 5 4% at Rougb-in
O Pass D Fail
100 x ine / Line # 2
TEST OR VERIFICATION STANDARD: For Altered Dad System and/or HVAC Equipment Change Oat
V1, ✓
Use one of the followingfour Test or Verification Standards for cum Ddanee=
9
Pass if Leakage Percentage 515% [100 x [ —'(Linc # 5) / (Line # 2)])
0 Pass O Fail
10
law if Leakage to Outside Percentage 5109'0 [100 x [_(Line # T) / (Line # 2)]]
O Pass O Fail
Pass if Leakage Reduction Percentage > 60% [100 x 110& tAine # 6) / L:ga. (Line #4)]]
°�
11
and Verification Smoke Test and Visual 'on -
e
/
O Pass Fail
12
Pass.if Scaling of all Accessm'ble Leaks and Verification by Smoke Test and Visual
- ° 4
0 Pass O Fail
Pass if 0neof-1AM#9throuzb#12 pan:�"`;
` : ` `` =" =
D Pass O Fail
1; the rte, veify that the above diagnostic test rea is
wee performed m coufan> mme with the rephements for compliance credit: L the undersigned, also certify that the newly -- -
installed or retrofit Aw-Distribution System Ducts, Plenums and Fans comply with Mandatory reqs speci5ed m
Section 150 (m) of the 2005 Building Energy E dency Standards.
Signature Dale- Installing Subcontractor (CD Name) OR
General Contractor Co. Name
A4 0/ og5
Residential Compliance Forms Mardi 2005 -
PE:00 V=
CERTIFICATE OF FIELD VERIFICATION & DIAGNOSTIC TffSMG O?fte 1 of s) CF -4R
53755 Navarro 1Q Qu�tltQttr� 9.53 -
Builder
io
Caffying Signafum .,
Fain: 'Re X G tit l a m
- -103q aunderName
Plan Number
-S corpMnaw
Ee Sample Howe Number
BM WOViden CHEM
S1redAddn : a gO3q Scoffed. 5,4e D#135 awmeswr, IMurfri e�4, 9�ScQ3
Copies to: Buitaev, RM Provider and
EMUS MTM COMPfI MCE STI TErdWff --
The house was: -/ N TeMd e 0 Appni ved as part ofsttatple tesfm& but was not tested
As the HM rater pavidmg test -ft sedfd vim, I oamy $at the hom ideal fled an this farm complies
with the diagnostic tested iegtt tls $s dredoed 1 On this fiam. The HIM rater must dwek.and verify that
The Iffin
the new dc�n'6uti n system is ducted and carred tepc is used before a CP -4B may be released on bail
and tested buildings, not relea9e CF -4R mmi a preP�9 completed and dgeed bas been reodved sample
)M The bmaller bn acW ofCF4R(haWkt1imCadficaw)
O New DioOkfim system is filly laded (Le;, does not use buHft cavities as plus or plate returns in lien of
ducts) -
13 New sYAMS whore doth back)4 rabbet adhesive dud tape is iosm&4 wasfic Bad draw bands are used in
e�biaafin with doth back4 robbertt ve drattapet4 seal Iedm attAdconnections.
/ O PADU <UM RRQD '8 vm Dwr LRmu4m mzDue Yoi copra IANCR-CRBDIT
PrOcedWWA-fidd vw #1006w acrd 4Or A Ma dwn are avwkrbk: w RlO� Arc RC4 3.
Dud Dec Leakage Testing Resorts
NEW-CONM-
UCTiON:
Duct hewdnflon TestResolts (CFM @ 25 Pa)
Measui ed
•values -
1
Eaoer Tested LeskWFlow in CFW-
2
Fan Flow: Calcalated (Nomink f M Cooling •/ O Heater or •' O Measured
.
EaWTotd Fan Flow in CFM:
f'�� ✓ ✓
3
1 Pass if Leate P 5 6% - [ 108 x # 1) /_—(Line # 2)Ij
D Pass l7 Fail
ALTERATIONS:
Dud System and/or 1QVAC
4
Enter Tested Leakage Flow in CTM limn CF-63L-63LPryFarist
-Testafmg tact Sys0em Priorto
Dud system Attera
_ - .�
° 5 0 �r s_�
td and/orC -Oat.
` : =
'J
Eater Tested L.eafmge Fes► in MC Final Tess of New Dad spsfew or uttered Dace System
y r t-2 =w:
5
Prater Ramon in Leakage for Abased Dud Sjrsbe�m
6
(C► ifs)
10 3-
7
Eater Tested Leake Flow is CFM to OaISide (Only if Applicable),
✓ ✓
Entire New Dud Sjst= -Paw if I.eWmW PoerewhW 5 6%
8
00 x # / Line#
❑Pass Fail
TEST OR VSBiFICAMN STANDAVM& For Altered Dasa Stators SmVer HVAC EWWW=cst Cbmwe.Ow
'r
Use we of Se feftmft flour Teat or Via Std fw cenaffiw=•/
9 Pon rfLealCW Peres 15%► [100 x [ (Line # 5) / (Line#2)Ij 0 Pass O Fail
10
Pass if Leakage to Oadide Pie 510% [108 x [__(Line: # 7) / (Line # 2)]]
0 Fass 0 Fail
11
Pass ifL=ImW Redtiction P > 6t3'1ti [100 x f j !! (v hw # 6) / / 3 S�(Line # 4)]g
ic3� c
�v O(Pass. 0 Fail
and Verification by Sruake Testand Visual
1 J
12
Pass if Seaft of alt Accessili1e heals and Veaficdion by Smoke, Test Sad Vsaal
;-' Wiz" -` M Fail
PassHOse ofLhm # 9 GrSu& # U pass�
"=1 0 Pass D Fail]
Residential Compliaaee Farms March 2005
PE:w OVI
CERTIRCAT9 OF FIELD WRIiCATION & DTAGNOSpI'IC T9SMG (Pads 3 of S) CF -4R
r -,m,: '�ZeX Grahc►Im
Saes Aadres: --ISO-39 Sj-o.4 Mk. J' u; tt n 1R 130
Plan Number
SMOeGr*VNumbe.-
hints r owner: CHEERS
fKuirvriela Ga CIZ2 rJCo3
Copies to: BnWw, HERS ProvIdce and BuBdbg Department
HERS RATER COMPLIANCE STATEMENT
The house v .P Tesed ❑ Approved aspart of smo* ttsfmg, but was not ttsted
As the HERS rater providing Me pri o if testigg sod field veI cel that the hoose identified on this form complies
with the c tested oomg reqs as wed on thin form.
101, In The C has provided a copy of CF4R (InsalMoin Vie).
Q� TH MMOSTATIC EXPANSION VALVE (!RV)
ProradJwnsTMVVMM OfdwMwAzdv erg , k, r whin are amfdable bi RdC34 Appeatfix AC
✓ ❑ RBl?aRIGERAwr CHARGB mR&vu
Verification for Required Refng Charge for Split System Spa= CDOft Systems without Thammta do Expansion
Valvas
Outdoor Unit Serial d
Location
Outdoor Unit Make
Outdoor Unit Model
COOIh%ow&y Bt ft
Date of Verification
Date of Refrigerant Cmuge (tk ' (must be dmonahi3r)
Date of'Iheffiooerhple f on I (must be m uft)
Ste�rd Chorea Mit (ou0dotg air drwbnlb 55 °P and ahpvel-
Note: The system should be installed and wed in aoeordiee wi& the mamifichneesswofficalim and
hotaller
verification shall be documented on (F -4R befit skating this V! m f a p IfouMoor air dry bulb is belmv 55 aFrater shalt
use the Attemative Charge Measree Procedure
I ✓ E3Yes i] No A copy of CF 6R (Ins;sllat = Catifirate) has been provided with re8cfgerant charge
Residential Compliance Farms
Merck 2005
✓
( Yes
O No
Access is provided for inspection. The procedure shall consist of
visual
vat that the T" is installed an the system and
❑
irsda of the shall be verified,
Yes is a pm I
.Pass 1
Fail
✓ ❑ RBl?aRIGERAwr CHARGB mR&vu
Verification for Required Refng Charge for Split System Spa= CDOft Systems without Thammta do Expansion
Valvas
Outdoor Unit Serial d
Location
Outdoor Unit Make
Outdoor Unit Model
COOIh%ow&y Bt ft
Date of Verification
Date of Refrigerant Cmuge (tk ' (must be dmonahi3r)
Date of'Iheffiooerhple f on I (must be m uft)
Ste�rd Chorea Mit (ou0dotg air drwbnlb 55 °P and ahpvel-
Note: The system should be installed and wed in aoeordiee wi& the mamifichneesswofficalim and
hotaller
verification shall be documented on (F -4R befit skating this V! m f a p IfouMoor air dry bulb is belmv 55 aFrater shalt
use the Attemative Charge Measree Procedure
I ✓ E3Yes i] No A copy of CF 6R (Ins;sllat = Catifirate) has been provided with re8cfgerant charge
Residential Compliance Farms
Merck 2005