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10-0150 (RER)P.O. BOX 1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 Application Number: f10'-000 00150 Property Address: x78650—CALLE-TAM O APN: 770-106-006-122 -000000- Application description: REMODEL - RESIDENTIAL Property Zoning: LOW DENSITY RESIDENTIAL Application valuation: 1317 : Applicant: Architect or Engineer: - CLAI&I 2 IVA 4 •BUILDING & SAFETY .DEPARTMENT BUILDING PERMIT 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 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 ay pplicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars IS5001.: (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 improvesthereon, 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 1, as owner of the property, am exclusively contracting with licensedcontractors 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—) I am exempt under Sec. , B.&P.C.Ar this reason Date: yOwner: 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 VOICE (760) 777-7012 FAX (760) 777-7011 INSPECTIONS (760) 777-7153 Date: 3/04/10 Owner: LECLERCQ ROBERT F 80600 VIA TALAVERA fi LA QUINTA, CA 92253 (! (760)777-6553 Contractor: t..,, n # 2�i0 Owner �67t✓�'"y-- .,� 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 Policy Number I c=at, 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 sho ecome suis ct to the w�,�m'pen tion provisions of Section 3700 of the Labor C shall for h ith comply pr i ons. 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 FF,ES. 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 Ameainformation is correct. I r e to comply with all city and county ordinances and state laws relatingstruct , and h eby t ize re resentatives of this county to enter upon the above-mentioned pec ' purpo ate:.4-1_SQalureIApplicant or Agen Application Number . . . . . 10-00000150 ------ Structure Information DAMAGE REPAIR + ENTRY ADDITION/VB/RES-3 ----- Other struct info CODE EDITION ---------------------------------------------------------------------------- 2007/2008 Permit . . . BUILDING PERMIT Additional desc . Permit Fee 33.00 Plan Check Fee 21.45 Issue Date . . . . Valuation . . . . 1317 Expiration Date 8/3.1/10 Qty Unit Charge Per Extension BASE FEE 15.00. 9.00-2, . 0000 --HND BLDG 501-2, 000 ---------------------------------------------------------------------------- 18.00 .... - Permit . . . ELECT - ADD/ALT/REM Additional desc . Permit Fee 18.00 Plan Check Fee 4.50 Issue Date . . . . Valuation . . . 0 Expiration Date 8/31/10 Qty Unit Charge Per Extension -BASE FEE 15.00 4.00 .7500 PER ELEC DEVICE/FIXTURE 1ST 20 3.00 ---------------------------------------------------------------------------- - Special Notes and Comments REPAIR OF DAMAGE BY VEHICLE AND PATIO ENCLOSURE TO MAKE NEW ENTRY/VB/RES-3 [CONVENTIONAL] THIS PERMIT DOES NOT INCLUDE REROOFING OF EXISTING DWELLING. 2007/2008 CALIFORNIA CODES. March 4, 2010 10:34:51 AM AORTEGA ---------------------------------------------------------------------------- Other Fees . . . . . . . . . BLDG STDS ADMIN (SB1473) 1.00 ENERGY REVIEW FEE 2.. ].5 Fee summary Charged Paid Credited Due Permit Fee Total 51,00 .00 .00 51.00 Plan Check Total 25.95 .00 .00 25.95 Other Fee Total 3.15 .00 .00 3.15 Grand Total 80.10 .00 .00 80.10 LQPERMIT Bin # City of La Quinta kdding & Safety UvWon P.O. Box 1504, 78-495 Calie Tampko La Quinta, CA 92253 - (760) 777-7012 Building Permit Application and Tracking Sheet Permit # U �v A Project Address: 74 O Owner's Name: P r fkg1fG e/LG A. P. Number: Address• OGiqD % v iu-A Legal Description: r City, ST, Zip: �,. p v / N l `Q r (� Cf 2 Q Contractor: 7G t9— �S'7 -- os -2! Telephone:7&o- 777- 6 tCS'.3 »: Address: O 6 `. LCC (i /� 2 C J Project Description: City. ST, Zip: ' PA I J` DN T (.9oc V Y Telephone: '� �- 7-0 !,v D®Q1(- Ov.SE State Lie. # : ' City Lie. C Arch., Engr., Designer. Address: City, ST, Zip: Telephone: c State Lie. #: Name of Contact Person: .r iQ— .— Construction Type: Occupancy: Project type (circle one): Now Add'n Alter Repair Demo Sq. FL: # Storiis # Units: Estimated Value of Project: 1 ZG U Telephone # of Contact Person: APPLICANT: DO NOT WRITE BELOW THIS UNE # Submittal Plan Sets Req'd Reed TRACKING PERMIT FEES Plan Cheek submitted ? Item Amount . Structural Cala. Reviewed, ready for corrections Plan Check Deposit Truss Cala. Called Contact Person Plan Cheek Balance Title 24 Cala. Plans picked up Construction Flood plain plan Plans resubmitted Mechanical Grading plan 21! Review, ready for correctionslissue Eleetrial Subeontactor 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 correctio a ��� Developer Impact Fee Planning Approval Called Contact PersonD A.I.P.P. Pub. Wks. Appr Date of permit issue School Fees Total Permit Fees 13 Date 3/4/10 No. 30623 CERTIFICATE OF COMPLIANCE Desert Sands Unified School District 47950 Dune Palms Road La Quinta, CA 92253 (760) 771-8515 4���1FIF,�sc�0 zoQ BERMUDA DUNES rn RANCHO MIRAGE CJ N INDIAN WELLS �.� PALM DESERT ,y LA QUI NTA 4 1-> N00 1p O Owner Robert Leclercq APN # 770-106-006 Address 78-650 Calle Tampico Jurisdiction La Quinta City La Quinta Zip Permit # Tract # No. of Units Type Residential Addition Lot # No. Street S.F. Lot # No. Street S.F. Unit 1 78650 Calle Tampico Unit 2 Unit 3 Unit 4 .1 Unit 5 Comments 30 Unit 6 Unit 7 Unit 8 Unit 9 Unit 10 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, cooking, eating or sanitation) or replacement mobila 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 30 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- Robert Leclercq Check No. Name on the check Telephone 760-777-6553 Funding Exempt BY Dr. Sharon P. McGehee, ,x Superintendent Fee collected /exam ted by PatrlCla BarbUZZa Payment Recd° "r'' .Over/Inder ' Signature NOTICE: Pursuant to Government Code Sectio/166020(d)(1), this will serve to notify you that the 90 -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 without embossed seal Embossed Original Building Department Applicant Copy - Applicant/Receipt Copy - Accounting P.O. Box 1504 LA QUINTA, CALIFORNIA 92247-1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 BUILDING. & SAFETY DEPARTMENT _r r PROPERTY OWNER'S, PACKAGE (760) 777-7012 FAX (760) 777-7011 Disclosures & Forms for Owner -Builders Applying for Construction Permits f11I -0.8 'ANT! NOWE TO EROEERTY OWNER Dear Property Owner. An. application for a building permit has been submitted in your name listing yourself as the builder of the properly improvements specified at 7R 6 S o ea t.[- _ZF o We are .providing you with an Owner -Builder Acknowledgment and Information Verification Form to make you aware of yoar responsibilities and possible risk you may incur by having this permit issued in your name as the Owner -Builder. We will not issue a building. permit until you have read, initialed your understanding of each provision, signed, and returned this form to us at our official address indicated. An agent of the owner cannot execute this note unless you, the property owner, obtain the prior approval of the permitting authority. OAR'S ACKNO'EDGWNT ANDVERMCATI.ON OF II OIi A'1F N DfREMONS. Read and initial each statement below to signify you understand orvenft this information. 1; I understand afire practice of -unlicensed persons is to liave the property owner obtain an "Owner-Builace' builbding permit that erroneously implies that the property owner is providing his or her own labor and material personally- 1, as dinging Owner-Builder, may be held liable and subject to serious financial risk for any injuries sustained by an unlicensed person and his or her employees while working on my property. 'My homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers on MY propertY- A1gL,2-. I understand building permits are not required to be signed by property owners unless they are responsible fo- the construction and are not hiring a Licensed Contractor to assume this responsibility. —L— 3. I understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. tj, % _ 4, Funderstand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. {2 /'L 5. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value of my construction is at least five hundred dollars' ($500), including labor and materials, I may be considered an "employer" under state and federal law. 6. 1 understand if I am considered an "employer" under state and federal law, I must register with the state and federal government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemp:oyment compensation for each "employee." I also understand my failure to abide by these laws may subject me to serious financial risk. 024P6Z. I understand under California Contractors' State License Law, an Owner -Builder who builds single-family residentia structures cannot .legally build them with the intent to offer them for sale, unless all work is performed by license, subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is performe, under contract with a licensed general building Contractor. dL4k - I understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable fc any financial or personal poyuries sustained by any subsequent owner(s) that result from any latent construction defects in the workmanship or materials. I understand I may obtain more information regarding my obligations as an "employer' from the Internal Revenue Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CST.B) at 1- 800-321-CSLB (2752) or www.csib.ca.gov for more information about licensed contractors. X10. I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the party legally and financially responsible for proposed construction activity at the following address: �% ehS© 'C 141.L) ? AJ4RIG ©. A.400/ A 17,4. '-A ? 27-S3_ U-10 L I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner -Builders as well as employers. 12.1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I have provided on this form. Licensed contractors are regulated by laws designed to protect the public- If you contract with someone who does not have a (kens,. the Contractors' State License Board may be unable to assist you with any financial loss You may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be in civil court. It is also important for you to understand that if an milicensed Contractor or employee of that individual or firth is injured while working on your property; You may be held liable for damages. If you obtain a permit as Owner -Builder and wish to hire Contractors, You wtl be responsible for verifying whetter or not those Contractors are properly licensed and the status of their workers' compensation insurance coverage. Before a building permit can be issued, this form must be completed and signed by the property owner and returned to the agency responsible for issuing: the perndt. Note: A copy of the property owner's driver's Reense, farm notarmO W4 or other verification acceptable to the agency is required to be presented when the permit is issued to verify the property owner's signature. / Signature of property owner /1 eG ��I'l Date: A1,44eClj / 2010 Note: The following Authorization Form is required to be completed by the property owner only when designating an agent of the property owner to apply for a construction permit for the Owner -Builder. AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BE Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize the following person(s) to act as. my agents) to apply for, sign, and file the documents necessary to obtain an Owner -Builder Permit for my project. Scope of Construction Project (or Description of Work): Project Location or Address: M &S D G 14LG S 7_,4n4 P1 C O ,4 A 4PZ714 6 Name of Authorized Agent: Address of Authorized Agent: Tel No I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above information and certify its accuracy. Note: A copy of the owner's driver's license, form notarization, or other verif cation acceptable to the agency is required to be presented when the permit is issued to verify the property owner's signature. Property Owner's Signature: Date: 27' "AN ADEQUATELY SUB DEBRIS CONTAINER IS REQUIRED ON THE JOB SITE DURING ALL PHASES OF CONSTRUCTION AND MUST BE EMPTIED AS NECESSARY. FAILURE TO DO SO - MAY CAUSE THE CITY TO HAVE THE CONTAINER DUMPED AT THE EXPENSE OF THE OWNER/ CONTRACTOR." A REINSPECTION FEE OF $36 WILL BE CHARGED IF THE APPROVED PLANS AND JOB CARD. ARE NOT ON. THE ,SITE FOR A SCHEDULED INSPECTION. �p CONSTRUCTION HOURS October fist - April 30 Monday , Friday: 7:00 a.m. to 5:30 p.m. Saturday: 8:00 a.m. to 5:00 p.m. Sunday: None Government Code Holidays: None May lsi - September 30th Monday - Friday: 6:00 a.m. to 7:00 p.m. Saturday: 8:00 a.m. to 5:00 p.m. Sunday. None Government Code Holidays: None . ra NO EXCEPTIONS! fj PLAN FOR REPAIRS AFTER AUTO COLLISION s , 1. ___ Construction is NOT PERMIiTFD on the following Code Holidays: nu Tt;dl zi 1Day Dr: Martin Luther IGngJr. Day Presidenfs,Day Memorial Day t; Independence Day Labor Day Veteran's Day" Thanksgiving Day Christmas Day ' f LECLERCQRESIDENCE 78650 CALLS TAMPICO LA QUINTAI CA 92253. t CITY OF LA OUINTA BUILDING &';SAFETY DEPT APPROVED FOR CONSTRUCTION DATE 3 4 10lo0 . BY-_, ti Grua. ANb 0#710 ro 4te"W 0" &ftv. ao � A1�rnd.l PLOT PLAN CALLE TAi APICO N.T.S. i3-1-10 row 1 �y ero" x c-s- PLAN FOR REPAIRS AFTER AUTO COLLISION ro~ x s*s" aro- x TV 4'0"X To" s'o- x 3-66" LECLERCQ RESIDENCE 78650 CALLE TAMPICO LA QUINTA, CA 92253 CITY OF LA QUINTA BUILDING &SAFETY DEP APPROVED FOR CONSTRUCTION DATE BY_._. so-xTV s^o" x 61" FLOOR PLAN N.T.S. 3-1-10 LECLERCQ RESIDENCE 78650 CALLE TAMPICO LA QUINTA, CA 92253 PLAN FOR REPAIRS AFTER AUTO COLLISION DINING RM 1 - NEW 3'0" X 6'8" ENTRY DOOR 2 - NEW 2'6" GARAGE DOOR 20 MIN. RATED 3 - MOVE EXTERIOR PORCH LITE 4 - NEW CEILING LITE i 5 - R 38 CEILING INSULATION I I EXTEND ENTRY TO EDGE OF PORCH REMOVE EXISTING DAMAGED DOOR AND CASE OPENING HALL 6'6" KITCHEN CITY OF LA QUINTA BUILDING & SAFETY DEPT. APPROVED FOR CONSTRUCTION DATE 8Y____-__ FRAMING DETAIL N.T.S. 3-1-10 IV r O .yam• T O 4r6rr 3 NEW 2X6 FRAMING 1 �R R-19 INSULATION INTERIOR DRYWALL D EXTERIOR STUCCO m CITY OF LA QUINTA BUILDING & SAFETY DEPT. APPROVED FOR CONSTRUCTION DATE 8Y____-__ FRAMING DETAIL N.T.S. 3-1-10 Prescriptive Certificate of Compliance: ttsj CF -1R ADD Residential AdditionsPae 1 of 5 Site Address:to) E)F EA of e en Agenc Date: -79-656 ChmATA4AAm BUILDING & SAFET 3�3 ?moo General Information Project Name A B I C D Climate Zone # 1� 7f Stories' Proposed see Note Standard Values From JA4 Table Building Type 11 Single Family ❑ Mu tClIffin'YrtiP Frnnt tlr e r ion: N, E,O W or Degrees loo Conditioned Floor Area of Aldition New Addition Size: 01 Less than or equal to 100 ft ❑ Less than or equal to 1000 82 (CFA): '% (Do not use this orm or additions greater than 1000 t1 NOTE: For Alterations to an existing home, submit a completed CF -IR -ALT Form. Exception: Existing HVA Csystems that are replaced or altered to serve the addition may be included on the CF -IR -ADD Form. Prescriptive Envelope Requirements for Additions Option 1: Use Option 1 for standard wood and assemblies meeting the Cavity R -value only. For all other use Option 2. • For 100 ftz additions; the Proposed values must be equal or greater than the Standard column or when indicated when using Package D, "Pkg D ". Enter all values in the Proposed Columns. For less than 1,000 ftpadditions must comply with "Pkg D" requirements unless indicated in the Standard Column. To meet "Pkg D" minimum energy compliance ree uirements, see RCMAppendix B, Table 151=C. Or §151(b) in the RCM. Enter all values in the Proposed Columns. Size of Addition 100 W or less Less than 1,000 W Component Standard Proposed Comment Standard Pro osed Comment Ceiling Insulation R-19 o Minimum Pkg D Table 151-C Wall Insulation R-13 Minimum R-13 Minimum Floor Insulation R-13 N Minimum Pkg D such as Concrete Sandwich Panel, Spandrel Panei, Logs, Straw Bale Panel and etc.... Table 151-C 5. Enter the Table number that closely resembles the proposed assembly. U- 7. Enter the Continuous Insulation R -value for the proposed assembly; otherwise, enter "0". U- 9. The Proposed Assembly U factor, Column J, must be equal to or less than the Standard U factor in Column E to comply. U- U- Fill out Fenestration factor SHGC factor SHGC Enter Proposed factor SHGC factor SHGC Fenestration 0.40 Pkg D V k Wt, 0.40 Pkg D to values then Skip Over reqs ProposedBelow Fill out Maximum GlazingProducts 50 ft- N,� fe To Roofing o Package D (20 /o of CFA) + Glass 1410 ftZ Additional Allowed Area Below Removed Fenestration Areas Below Radiant Barrier N/A Pkg D Table 151-C Roofing Pkg D See Roofing Products Below Pkg D See Roofing Products Below Opaque Surface Details For the furred portioned of Mass Walls see Furring Strips Construction Table below. A B I C D E F G I H I I J Proposed see Note Standard Values From JA4 Table Framing Thickness,*factor4imber5 Framed Continuous JA4 Proposed Tag/ Assembly Name Material Spacing, IDS or Type' and Size Z or Other' Cavity Insulation R-valueb R- alue' Assembly Cell Value$ Assembly U-factor9 .. • N o Note: For furred assemblies, accounting for• Continuous Insulation R -value, see Page JA4-3 and Equation 4-1. For calculating furred walls use the Mass and Furring Construction table below. 1. For Tag/11) indicate the identification name that matches the building plans. 2. Indicate the Assembly Name or type: Roof/Ceiling, Walls, Floors, Slabs, Crawl Space, Doors and etc... Indicate the Frame type and Size: For Wood, Metal, Metal Buildings, Mass, enter 2x4, 2x6, or etc... see JA4 for other possible frame type assemblies. 3. Enter the thickness for mass in inches or Spacing between framing members enter; 16"or 24"OC; or Other for all other assembly description such as Concrete Sandwich Panel, Spandrel Panei, Logs, Straw Bale Panel and etc.... 4. Based on the Climate Zone; enter the Standard U-jactor from Table 151- Cfor each different assembly Name or type. 5. Enter the Table number that closely resembles the proposed assembly. 6. Enter the R -value that is being installed in the wall cavity or between the framing; otherwise, enter "0". 7. Enter the Continuous Insulation R -value for the proposed assembly; otherwise, enter "0". 8. Enter the row and column of the U factor value based on Column F Table Number and enter the Assembly U factor in Column J. 9. The Proposed Assembly U factor, Column J, must be equal to or less than the Standard U factor in Column E to comply. Registration Number: 2008 Residential Compliance Forms Registration Date/Time: HERS Provider: August 2009 Prescriptive Certificate of Compliance: CF -1R ADD Residential Additions (Page 5 of 5 Site Add re �� / /� Enforcement Agency: Dag: " tj HERS VERIFICATION SUMMARY - The enforcement agency should pay special attention to the HERS Measures specified in this checklist below. A completed and signed CF -4R Form for all the measures specified shall be submitted to the building inspector before final inspection. Duct Sealing & Testing HERS verification is required for this measure. ❑ YES V NO YES: In all Climate Zones, if a new space -conditioning system (HVAC equipment and ducting) is installed to serve the addition alone, the ducts are to be sealed and tested per §151(f)10. ❑ YES OL NO YES: In Climate Zones 2 and 9-16, if more than 40 linear feet of new or replacement ducts are installed in unconditioned space to serve the addition, the ducts are to be sealed and.tested per § 152(b) I D. ❑ EXCEPTION: Existing duct systems that are extended, which are constructed, insulated or sealed with asbestos. ❑ YES IVO YES: In Climate Zones 2 and 9-16, if the existing HVAC equipment is replaced (including replacement of the air handler, outdoor condensing unit of a split system, cooling or heating coil, or the furnace heat exchanger) and will serve the addition, the ducts are to be sealed and tested per § 152(b)1 E. ❑ EXCEPTION: Duct systems that are documented to have been previously sealed confirmed through HERS verification in accordance with procedures in the Reference Residential Appendix RA3. ❑ EXCEPTION: Duct systems with less than 40 linear feet in unconditioned space. ❑ EXCEPTION: Existing ducts stems constructed, insulated or sealed with asbestos. Refrigerant Charge - Split System HERS verification is required for this measure. ❑ YES 'R NO YES: In Climate Zones 2 and 8-15, if a newly ducted split A/C or heat pump is installed to serve the addition alone, a refrigerant charge measurement shall be verified per §151(f)7A. ❑ YES IXNO YES: In Climate Zones 2 and 8-15, if the existing HVAC equipment is replaced (including replacement of the air handler, outdoor condensing unit of a split system, cooling or heating coil, or the furnace heat exchanger) and will serve the addition, a refrigerant charge measurement shall be verified per §152(b)IF. Central Fan Integrated Ventilation System — Airflow and Fan Watt Draw - do not apply for additions 1,000 ft2 or less. Ducted Split Systems - Air Conditioners and Heat Pumps: Airflow and Fan Watt Draw HERS verification is required. ❑ YES NNO YES: Inbimate Zones 10 through 15, if a new space -conditioning system (HVAC equipment and ducting) is installed to serve the addition alone, the airflow and fan watt draw shall be verified per § 151(f)7B. ❑ YES JKNO YES: In -Climate Zones 10 through 15, if the existing space -conditioning system (HVAC equipment and ducting) is replaced and will serve the addition, the airflow and fan watt draw shall be verified per §152(b)1F. Documentation Author's Declaration Statement • I certify that this Certificate of Compliance documentatior-19 accurate and co I e. Name:�L� eC�CrG e o Y' gn re: Company: Date: Z-4- 2m10 Address: If Applicable ❑ CEA or ❑ CEPE (Certification #): City/State/Zip: Phone: Responsible Building Designer's Declaration Statement • . I am eligible under Division 3 of the California Business and Professions Code to accept responsibility for the building design identified on this Certificate of Compliance. • 1 certify that the energy features and performance specifications for the building design identified on this Certificate of Compliance conform to the requirements of Title 24, Parts I and 6 of the California Code of Regulations. • The building design features identified on this Certificate of Compliance are consistent with the information provided to document this building design on the other applicable compliance forms, worksheets, calculations, plans and specifications submitted to the enforcement agency for approval with this building permit application. Name:ber-� lerG Sign re Company: Date Address:. License: City/State/Zip: Phone: For assistance or questions regarding the Energy Standards, contact the Energy Hotline at: 1-800-772-3300. Registration Number: Registration Date/Time: HERS Provider: 2008 Residential Compliance Forms August 2009