0110-108 (SFD)LICENSED CONTRACTOR 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 # Lic. Class` Exp. Date
4:x:31. t3
,Date R + !�- -�' fSignature.of Contractor
OWNER-BUILDER DECLARATION ;
I hereby affirm under penalty of perjury that I am exempt fromtheContractor's
License Law for the following reason:
( ) 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 & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
( ) I am exempt under Section . , B&RC. for this reason
Date - Signature of Owner.
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty .of perjury one of the following declarations:
I( ),> 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 thispermit 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 & policy no. are:
Cartier STATE FMID Policy No. 1280."0-01
(This section need not be completed if the permit valuation is for $100.00 or less):
. ( ) 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,l should become
subject to the workers' compensation provisions of Section 37,00 of the Labor
Code, I shall forthwith comply with those provisions.wy
Date:j✓. �s� pplicant
t
Warning: Failure to secure Workers' Co pensation overage is unlawful, and
shall subject an employer to criminal penalties,And civil fines up,tto $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.
IMPORTANT Application is hereby made to the Director.of Building and Safety
for a .permit subject to the conditions and restrictions set forth on his
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 applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
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.
1`6ertify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned prop4rty for inspection purposes.
Signature (Owner/Agent) "' Data AI �✓e� ��' l
`'��~w js
BUILDING PERMIT I. PERMIT#
DATE. ."VALUATION LOT 61aCi-3'€et TRACT
864r449M, 2.01 1SIK 76
JOB'SITE ejy( qp�
ADDRESS
3 wl20 A YAinf.�/a,R:'A VALVEJO
6+ ._
APN
773-223-001
OWNER -
CONTRACTOR/DESIGNER/ENGINEER
DAVM11M?:
PAIL FIC TRADES C0.NTrfWC7.1014
1719 03'MEM0117111
1719 3. °s°��'MOM
3 ocvlo1S1'f3.1; CA 92054
8 OCTANZME Oft. �?QRZ
�3Ft,1a�a7»130�.9 ' . 395
r
USE OF PERMIT
S -Kt.) -1LOT 32 - C VER, TOVfFA PZRMIT O.&`'ra0� ENC;<XLw
3t;`iK'9V•�,3.,:f�aa', k�r�0USPs'S. �1 i DRIV YA.Y Ayr.�,.t>.��ii°a
fJ
TRACT t ONPIT1€UC TION 11307,00
PIP
POIZC k113 X111O. 56.00 .,F
CITY OF LA 4
L A
0.i��v.�§,a;}.EJOA1�F�^RT 516,00 S
Flf�OF ��4-
't
AX= CO.Sr OF CORVMUt"J74QN
K449-
Pnl kwr 'li It ; r91
C•'ONSTi3.1,1CT3100 M 101-000-418-000 8331.83
18
i LAR C13VXre PUI Z 101-000-439-318
Frol+.Lllil'M111f' 1€31-000.439.318 533 ,CT
MY.�C:HANI'CALFL $0.0
k" ECT41ICAL FEV $107,72
PIX11 S'INGFE13 121-000.419-000 $113.00
1.1�TIZIy��Ia�iyd��i, +�L��`��f �3W FEE - RESED
qF S10 p1.-,[0�000p0-24�1-('�M p88,64
�
0.EV1?WPER1i13PA k'ME 7fp7Vir0V
A
PP.M18S P1.A34 101 -0€30-441- 345 �10rJ.00
MM -1 -TOTAL COYMIRJ:x'C1109 AM PLAN CMICK.
$3,381.71
S PRE FAIDEM
-$250.00
jf
1✓�/
RECEIPT
DATE
BY' '
DATE A D
INSPECTOR
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
( S- �i
Ducts
Slab Grade
_ _ _�
('G
Return Air
Steel
Combustion Air
Roof Deck
O.K. to Wrap
�' Zaf
xhaust Fans
F.A.U.
Framing
Compressor
Insulation
y�//
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
2-
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
%_ Gj�
Heater Final
_/ _
Water Piping
F `-�
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
ILL� � O � �T
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Z-
Utility Notice (Perm)
- G(
t7 ,
CITY (,F L-''A QUINTA
�FboF o BUILDIN a .s 77-701
DEPARTMENT !`
77-7012 r }
Y
�F?Z IIP .PTION REQUEST LINE
r
777-7153
S v (7 Owner AW ID/MILLER
'Contractor P�ACTFIC TRADES
r I - Permit Number 0110-108
POST ON JOB IN CONSPIC `
UOUS PLACE
INSPECTOR MUST SIGN ALL APPLICABLE SPACES
52-020 AVENIDA VALLEJO \
JOB ADDRESS - � .
SFD - LOT 22 - MASTER, TOWER -PERMIT DOES .
'NoT INCLUDE BLOCK WALLS, POOL/SPA OR
DRIVEWAY-APPROACH t. r Z
Gkz1.Y" t 2 G 0 r. R'
TYPE OF INSPECTION DATE IN :
FOUNDATION & SETBACK _DI
FOOTING STEEL
> l
MAIN GROUND SYSTEM -�
GROUND PLUMBING
PRE—GUNITE - i3
DO NOT POUR CONCRETE UNTIL ALL ABOVE HAS BEEN SIGNED
CONCRETE SLAB
JOISTS & GIRDERS
ELECTRICAL GROUND WORK
DO NOT POUR CONCRETE UNTIL ALL ABOVE HAS BEEN SIGNED
ROUGH ELECTRIC t ,
ROUGH PLUMBING,
ROUGH GAS & GAS TEST
HEATING & VENT- A/C
FIREPLACE _ '} '_
• ROOF , ; y . �' . �• -
BOND BEAM
O.K. TO WRAP l l 2a —a l k'• ,. `.
:GROUT ❑ 4' eO 8' r ..
FRAMING I k
' Rwe.
INSULATION 1= IG — Ol '
I'
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED
\\ DRYWALL INTERIOR
2- , —O1. !
EXTERIOR LATH
POOL PRE PLASTER 2 i. Z U
POOL'FENCE & GATE I
i
S E SEPTIC TANK 11_y_O
• _� ,.. . � i "FINALS
ct
ELECTRICAL «. ,
PLUMBING }
FINAL GAS TEST
HEATING-A/C
HOUSE NUMBERS
JOB COMPLETED iL
4 TEMP POWER
�• s
F>.
ABOVE APPROVALS
• � • � DO NOT INCLUDE RIGHT TO
TURN ON UTILITIES OR OCCUPY BUILDING
- .-, , 2 -0 -S-
4
u�lctcv
P.O. BOX 1504
Building , r 78 495 CALLE TAMPICO
Address 1Al' LAQUINTA, CALIFORNIA 92253
OwnerMailin
/
Address / 7
City r Zip Tel.
Contractor
Address
City Zip Tel.
State Lic. City
& Classif.
Arch., Engr.,
Designer. 5
Address Tel.
05 -
APPLICATION ONLY ,\�$
\O
L�
BUILDING: TYPE'CONST. OCC. GRP.
A.P. Number 77 '/� CJU
Legal Description Ze> :r" '-
Project Description
r-
' Sq. FtNo. No. Dw.
=Size';:)1, a3,2� Stories Units
New IDS Add ❑ Alter ❑ Repair ❑ Demolition ❑
City Zip State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am,Itcensed under provisions of Chapter 9 (commencing with Section
7000) of Division 3 of the Business and Professions Code, and my license is in full force and
effect.
SIGNATURE w `+ DATE
OWNER -BUILDER DECLARATION
I heieby affirm that I am exempt from"tre Contractor's License Law for the following
reason: (Sec. 7031.5.pusiness and Prolessions Code: Any city or county which requires a
permit to construct, .atter, improve, demolish, or repair any structure, prior to its issuance also
requires the applicant for such permit to file a signed statement that he is licensed pursuant to
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Professions Code, or that. he 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 live hundred dollars (5500).
t: 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, Buisness and
Professions Code: The Contractor's License Law does not apply to an owner of property who
builds or improves thereon and who does such work himself or through his own employees,
provided that such improvements are not intended or offered for sale. If, however, the building
orimprovement is sold within one year of completion, the owner -builder will have the burden
of proving that he did not build or improve for the purpose of sale.)
I 11, as owner of the property, am exclusively contracting with licensed contractors to con-
struct the project. (Sec. 7044, Business and Professions Code: The Contractor's License Law
doesnot apply to an owner of property who builds or improves thereon, and who contractsfor
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
1-1 1 am exempt under Sec. B. & P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
n Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed it the permit is for one hundred dollars ($100) valuation
or less.)
I certify that in the performance of thg work for which this permit is issued, I shall not
employ any person in any manner so as to become subject to the it
Compensation
Laws of California.
Date Owner
NOTICE TO APPLICANT: If, after making this Certificate of Exemption you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
Ihereby affirm that there is a construction lending agency for the performance of the
work for which this permit is issued. (Sec. 3097, Civil Code.)
Lender's Name
Lender's Address
This is a building permit when properly filled out, signed and validated, and is subject to
expiration if work thereunder is suspended for 180 days.
I certify that I have read this application and state that the above information is correct.
I agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives sof this city to enter the above-
mentioned property for inspection purposes.
Signature of a0plicant Date
Mailing Address
City, State, Zip
Estimated Valuation
BY:
PERMIT
AMOUNT
Plan Chk. Dep.
Front Setback from Center Line
Plan Chk. Bal.
Rear Setback from Rear Prop. Line
Const.
Side Street Setback from Center Line
Mech.
Side Setback from Property Line
Electrical r
FINAL DATE
Plumbing
Issued by:
S.M.I. -
Validated by:
Grading
Driveway Enc.
Infrastructure
z
I
GI IT Orr
91140r= n.
i
TOTAL
r/)
REMARKS
ZONE:
BY:
Minimum Setback
Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE
INSPECTOR
Issued by:
Date Permit
Validated by:
Validation:
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION
Desert Sands Unified School District -
47-950 Dune Palms Road
Notice: r La Quinta, CA 92253
Document Cannot Be Duplicated 760-771-8515
CERTIFICATE' OF COMPLIANCE
Date 10/16/01 t APN#' 773-223-001
No. 22588 Jurisdiction La Quinta
Owner NameDavid Miller Permit # 01.10-'108-
No. 52-020 Street Avenida Vallejo Log #
City La Quinta Zip, _92253 Study Area
Tract # BLK 76 Lot # 22 Square Footage 1397
Type of Development Single Family Residence No. of Units 1
Comments
At the present time, the Desert Sands Unified School District does not collect fees on garages/carports, covered
patios/walkways, residential additions under 500 square,feet, detached accessory structures or replacement`mobilehomes. It
has been determined the above-named owner is exempt from paying school fees at this time due to the following reason:
EXEMPTION NOT APPLICABLE ,
This certifies that school facility fees imposed pursuant to Government Code 53080 in the amount of
2.05 X 1,397 •or $ 2,863.85 the property listed above and ,tha0 uilding -
permits and/or Certificates of Occupancy for this square footage in this proposed project may now'be issued
Fees Paid By CC/Mission Oaks National Bank J.R. Rodriguez_ Telepin+one 805-1251
Name on the check r� ;
By - Dr. Doris Wilson
Superintendent
Fee collected /exempted by Juanita Green Payment Received $2,863.85
Check No.,. 10912 i
Signature ` .
�No
TICE: Pursuant of s mbly Bill 3081 (CHAP 549, STATS. 1998) this will serve to notify you that the 90 -day approval period in which you may protest the fees or other payment identified
bove will begin to run r m the date on which the building or installation permit for this project is sssued or on which they are paid to the Distdct(s) or to another public entity authorized to
ollect them on the Di ct('s)(s') behalf, whichever is earlier.
Collector: Attach a copy of county or city plan check application form to district copy for all waivers.
Embossed Original- Building Dept./Applicant' Copy Applicant/Receipt Copy - Accounting .
i. 1 .
{ 01 /•12/.01 14'. 90 FAX 17808049062 COMMONWEALTH TITLE,_
RECORDING REQUESTED BY:
AND WHEN RECORDED MAIL THIS DEED AND,'
UNLesa oTNBRWIsa SHOWN BELOW,
3 MAIL TAX STATEMENTS T0:
rWi11•iam', Thoi¢,ae Isu� °in k
• ..
Power Brokers
B.O. Box 134'
..
"�
La Quiz►t&. CAA 92253
ZI
SPACE ABOVE THIS LINE FOR RECORDER'S USE
A.P.N:�: -223-001'
rant DeedYt.
Tha:underslgned grantor(s) declare(a):
Qocumentary transfer tax to $
t ( xQucomputed on full value of property conveyed, or
{ ;V-1 computed on full value less value of lie) a'gnd`encurrbrances rerflaining afllme of $818. "
( } unincorporated ares:. ( ) Clty of � f
':i:. `.' :� . , and
FOR A VALUABLE. CONS IDERATION recaipt of which is hereby acknowledged,
BILL RILEY
u
hereby GRANT(S) to WILLI& THOMAS BUFIN, an
unmarried can
the real propent -in the'City of La Quint&
County of Rlvers14a
stale of Celifomis, described es
Lott ... -'22 :of Block 76 Unit` ;i*a,
Santa Carmelite at Vale La -
_,'
Quints, 8B ,p'er':oiap recorded in Book
tPages, &f. Maps, Records. of' Riverside
County, 'Califf n a..-
A
oaleQ g 3, 2001
Slgnat 4 cf Grar tot
State of. California
•'countyof s" ).SS.
,:BILL RILEY;
ion _ - , — D®rcrs me,
ti
i . ,DeraonSlly aRpeared'
'$ 'ILL RIuj
.........-•-�---� �,
•personally known to me (or proved of puttefactory
— - —
;,evidenee) to bo ins pervar(t) whose rarne(s) Israre subscribed tv the
"',-within Imstrumenl and acknowte"dged to me that'he/shs/:hey oxooutod
Lhe• sarne In hia/her/lholr eutherited— cap sollypes),' and that fry
hlbfieNlhelr alanature(a). on the Instrument the,person(s), or the entlty
'upon behalf of which the pereat(s).eetea, axsevted the instrumam.
WI1TNEt36 my nand 2nd offlev Seel,
' SlSnatu�e
_
• MAIL TAX.$TATEMENT6'TO,
— - - 'd; b.?8> oN.S',83',29
a�
u. _ H.3M0� k4hZS .l}l l0 �.Z 'r,�,Q��,
- 1
RC DISTRICT - PLANNING REVIEW FORM
This form is to be used by CDD staff for, -review of single family dwellings.in the RC (Cove'
Residential) Diste!ict per Section 9. 50.090 of the Zoning Code. Its purpose is to determine:
1) that the proposed house +design does not duplicate the same architectural style of .any
house within 20-0- feet of the applicant,, and/or--2)-�if there' is -a -need -for the applicant -to file for
Master Design Guidelines. If the applicant does need to file a Master Design Guideline, please
transmitted this information to the Building and Safety Department as,part of your correction
list. Please attach additional explanations as necessary.
APPLICANT Pacific Trades >
SITE ADDRESS. 52-020 Avenida Vallejo
APN 773 _ 223 - 001 CASE NO.: 2001-559 Y
-- LEGAL: LOT
22 BLOCK 76 UNIT S.C.@V:L.Q.
CHECK AND APPROVED BY: Greg - Trousdell DATE'
Inform the assigned Building plan checker upon your assignment to this case. The CDD
Executive Secretary, maintains a log book to track applications and assign case numbers.
N
�e
REQUIRED ITEM
Y N
COMMENT/CORRECTION
Verify legal and APN.information
Consistent with MDG on file (as
.applicable
MDG filing required (5 filings since
9/3/98)
p
Architectural variety within �eet of
the surrounding area:
ved b Gomm ° o
G�ty Vat '
\s r
s0 �a n features
svv� God
Othertvoements:
i<
�X�
*,,Certificate of-Occupandy �}
City of L.a Qu"inta.�
Building and Safetv Department �`eMOF�
This Certificate issued pursuant to the requirements of Section 109 of the Uniform 'Building Code,
certifying that, of the .time of issuance, this structure was in compliance with the various ordinances
of the City.regu/ating building construction or -use. For the following:
-BUILDING ADDRESS: 52-020 AVENIDA VALLEJO
Use Classification: SINGLE FAMILY DWELLING Bldg. Permit No.: 0110=108
Occupancy Group:. R-3, U-1 Type of Construction: VN , Land Use Zone: RC
Owner of Building: DAVID MILLER Address: 1719 S TREMONT A
.City: OCEANSIDE CA 92054
By:. KIRK KIRKLAND
-- Date: 2-26-2002
Building Official
POST IN A CONSPICUOUS PLACE -
;.«i:
.`.z.
EMS Ener Mana ernent-Services
A Division of The Air Conditioning Company
Special (Votes
As per California AB -970 Effective June 1, 2001, Basic
Prescriptive Package ®, some or all of the following
items may be required on this job. Refer to the Title 24
report, CF -1 R (addendum) for specific items listed.
• The HVAC system inclu' des credit for a Radiant
Barrier installed per section 0.13 of the Cal Title 24
residential manual effective June 1, 2001.
e High Klass design — Verify Thermal Klass.
• A certified HERS Rater must perform a Diagnostic
fan flow test or verify installation of a TXV. -
• The HVAC system is using reduced duct leakage to
comply and must have diagnostic site testing of
duct leakage performed by a certified HERS Rater.
The results.: of .the diagnostic testing must be
reported on a CF -6R Form.
• Maximum fenestration "U" factor must be .65 or
sower. Window SHGC factor must be .40 or lower.
See 2001 AB 970 Energy Efficiency Standards for Residential and Nonresidential
Buildings Alternative Component Packages, Tables 1-Z1 through 1-Z16 for all
other features, devices and systems for Package D.
41.485 Adams Street, Unit C - Bermuda Dunes, Ca. 92201 - (160) 360.46311 Fax (760) 360-W4
License No. 315M I Email: Fretm ja&4&.net
T24 Calcs - Manual D Duct Design - Tight Duct Testing - CHEERS Rater - Air Balance - CO2 Testing
I {I
EMSEnergy" M2tna ernent Services
A Division of The Air Conditioning Company
k '
Ref: AB 970 Ruling Effective June 1, 2001
The enclosed "Installation Certificate" forms are included for
the builder/owner to give to the appropriate sub -contractor or
tradesman to fill out and sign. These will be given to the
builder/owner/building, inspector and the HERS Rater prior to I`
final approval by the building department. .
Because the approvedCal. Title 24 shows energy credits
taken, the forms CF -6R• along with forms CF -1 R must be
presented to the HERS Rater prior to testing.
Installation Certificate HVAC Systems.
" water Heating Systems.
Fenestration Glazing
Duct Leakage & Design Diagnostics
" Duct Location & Area Reduction.
" Insulation Certificate
41485 Adams Street, Unit C - Bermuda Dunes, Ca. 922M - (760) 360.46311 Fax (/60) 360-3074
Ucense No. 315890 / E4WI: Fmn.jad ftte.net
T24 Calcs — Manual D Duct Design — Tight Duct Testing — CHEERS Rater — Air Balance — CO2 Testing
'I p
i
INSTALLATION CEItTMCATE (Page 1 of 8) CF -6R
Site Address ermit 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 11
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 (pk&,, CEC Certified Mfr Name Identical (AGUE, etc.)' Location Piping
beatmimm and Model SWEbMSv +tee f2CF 1R valuel (attic. etc) R -value (13tU jW Btnlhd--
i. f i
Equip. Equipment
Certified CaMmssor # of Efficiencyt Duct Cooling Cooking
Type (pkg Unit Mfr Name and ° Identical (SEER, etc.) Location Duct Load Capacity
I.
hcat mW Model Number Smetana UCLAR valuel (attic, dc.) R -value rl
.t
d
1. >readsgreater AmorepatW.
1,'the undersigned, verify that equipment listed above is: 1) is the actual equipment installed, 2) egaivalent to or more
efficient than that specified in the certificate of compliame (Form CF -1R) submitted for compliance with the Er eW
Efficiency Standards for residential buildings, and 3) equipment that meets or exceeds the apprc priatc rep rams for
Wired devices (fraam the App1%zuw a Effldency R%wZ&ons or Part 6), where applicable. '
.Signature, Date Installing Subcontractor (Co.'Name)
OR General Contractor (Co. Name) OR Owner
u WATER HEATING SYSTEMS:
i
DiA' it ion lFRecir- # of Rated' Tank Effi- ib Extemal
Beater Clic Cettiw Mfr Type (Std, cumtion, ldeatiaal hq= (kW volume cie--yz Standltyz rlustilation
Type Name & Madel Number { Point -of -Use) Camol Type Symm or Btaft) age "w (EF, RE) Lass (%) R value]
Y l
2 Forman gas ere np (rated iapot of I= than or equal to 75j= Bm/hr), deetrk eedsibma and best pomp water heaters; Dist Energy Fad.
For large gas aterW water beaters (rated tapat oft¢ea - thm 75.000 BW&r).list Recovery Fffi6mg Stndby Loss and Rated h ptu.
`-�
For mous gas watt treaters, rist FizovaY ETwica4aDd Rated h
3. R-12 extenal insulation is manda wy for storage water heaters with an energy factor of has than 0A. ,
Faucets:& Shower Heads:
All faucets and showerheads installed are certified to the Commission, pursuant to Title 24, Part 6, Section 111.
1, the lmdersigoed, verify that equipment listed above my -signature is: 1) the actual equipment installed; 2) equivalent to or
more efficient than that specified in the catificate of compliance (Form. CF -1R)' for compliance with the Energy
Ef fWaxy Standmrls for.resideatial buiklmgs;- and 3) egwpmt that or exceedsthe appropriate for
manu&dtued devices (fmm the Appliance Effide(cy Reguladm or Part 6), where applicable.
'Signature, Date Installing Subcontractor (Co. Name) OR
General Contractor (Co. Name) OR Owner iE
i�
COPY TO:. Building Department
HERS Provider (if applicable)
Building Owner at',Occupancy
i
�` January 4, 2001 '?
wnvura.u�crnvuua.a�� -- - �!
2. —
3. _
4. _
6.
7.
8.
10. _
11. a
'12. _
13.
14. — a
Manus fenestrations products use the values from the product label. Field fabricated mon products use the
default values from Section 116 of the Energy Efficiency Standards.
s Installed U-Factor must be less than or equal to values from CF-1R Installed SIiGC must be less than or equal to va!I=
firm CF:1R, or a shading device (werior or o is installed as specified on the CF-IR. Alternatively, installed
weighted average U-Factors for the total fenestration area are less than or equal to values fiom CF-IPL
Ij
I, the vetiff that the feaestraii�/ ng listed above my sbmatm 11) is the actual fmoseraticin pro duct
2) is equivalent tum has a lower U- dw and her SHGC titan that specified in the certificate of compliance
(Pori CF 1R) WMatted for owe with the Enav Amdm& for residential and 3) the product
mmftormcaedsthe qVwpmwftnqmmmmb ford&-yam(ftompart6),a ,
r
Item #s Signature, Date Installing Subcontractor (Co. Name) OR li
(if applicable) General Contractor (Co. Name) OR Owner
OR Window Distributor
Item #s $ignaum Date Installing Subcontractor (Co. Name) OR
(if applicable) General Contractor .(Co. Name) OR Owner
OR Window Distributor
CI
Item #s Signature, ,Date Installing Subcontractor (Co. Name) OR.
(if applicable) General Contractor (Co. Name) OR Owner
OR Window Distributor d
COPY TO Building Department
HERS Provider (if applicable)
Building Owner at,,cy
I
January 4,2001;
�t
0 -W -j
INSTALLATION CERTIFICATE (Page 3of8 CF -6R
Me Address Permit Number
DUCT LEAKAGE AND DESIGN DIAGNOSTICS
0 DUCT LEAKAGE REDUCTION
Test Results
PA)
Test Lealcage (CFM)
Fan Flow
If Fan Flow is Calculated as 400 ,cfinftn,x miriber of tons, or as 213 x Heating Capacity
in Thousands of Btu/hr, enter calculated value hue
If fan flow is meastn ed, enter measured value ban
Leakage Faction — Tea 1Aalmge/(Measwed or Calculated Fan Flow)
Pass if lealcap faction 0.06
13 For AEROSOL TYPE SKALAM ONLY - The following diagnostic tesft was Completed:
Duct Fan ftessurization at rough -in measured leakage (C]"
CHECK AMR FIN MMG WALL:
11 Yes 0 No - 13 ftesstire pan tea or House pressurization test
13 Yes 13 No 13 visud Inspection of Duct Connections
13 13
Pass'. RM
13 THEMOSTA-m-EXPANSION VALVE MM
13 Yes 13 No Thermostatic Expansion Valve (Or Commission approved
equivalent) is installed and Access is provided for inspection 13 13
Yes is a pass Pass !I , Fail
0 DUCT DESIGN
[3. yes C] No ACCA Mamial D Design calculations have been completed,
Duct Design is on the plans and duct installation matches:
plans.
2. b Yes o No TXV is installed or Fan,flow has been verified. If no M.
verified fan flow matches design from CF-lF-
Measured Fan Flow
13 [3
Yes for both I and 2 is a Pass Paw Fall,
13 I, the undersigned, verifyffiat the above diagnostic test results and the work I performed associated with the tests) is in
conforma , nce with the tequuemmts for compliance credit DU 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 kuirer6eM for
compliance credit.]
Tests Signah—m-1 Date bstalling Subcontractor (Co. Nam) OR
PCienual Contractor (Co. Name)
erformed
COPY TO: Building Department
HIM Provider (if applicable)
Building owner at Occupancy
January 4, 2001
INSTALLATION CERTIFICATE (Page 4 Df 8) CF -6R
Site Address Permit Number
DUCT, LOCATION AND AREA REDUCTION DIAGNOSTICS
'I
a
❑ DUCT IN CONDMONED%SPACE
❑ yes. ❑ No Duct in conditioned space criteria matches CF -1 R ,t
❑ ❑
❑ REDUCED DUCT SURFACE AREA
Measured dud exterior surface area in the
Attics
Crawispaces
Yes is a Pass Pass : Fail
unconditioned dud locations (square feet): i
Basements
O0her. (e.g., garages, etc.)
❑ Yes ❑ No Duct surface area matches CF -1R? ® I.13
Yes is a Pass Pass Fail
❑ I, the , verify that t6 duct mu&ce area and dud loraum cbimed for dud sodace ares redubons and duct-
location improvements beyond *= covered by default assumptions match &-cera on the p ls. en
HERS provider a copy of the CF -M signed by the buildca employees or sab-oohs � g and
the
installation meet the nXidirements for compliance credit.]
J
Tests Signature, Doe Installing b aCt" (Co. Name) OR
Performed: Geral Comador (Co. Name)
COPY TO: BWft Depatmew
HERS Provider (if applicable) .
Building O%ma at Occupancy
I�
!i h
i G
January 4, 2001
.
i
INSTALLATION CERTIFICATE (Page .5 Of 8) CF -6R
s� oda,
ermlt umber
BUILDING ENVELOPE LEAFAGE DIAGNOSTICS
❑ ENVELOPE SEALING INFILTRATION REDUCTION
Diagnostic Testing Results
Building Envelope Leakage (CFM @ 50.13a) as measured by Rater
1. ®
J3
Is measured envelope leakage less than or equal to the required level
Yes
No
from CF -1 R?
2. 13
❑
Is Mechanical Ventilation shown as required on the CF -1 R?
Yes
No
2a. []
❑
N Mechanical Ventilation is required on the CF -1 R (Yes in line 2), has
Yes
No
it been Installed?
2b. ❑
❑.
Check this box yes N mechanical ventilation is.required (Yes in line 2)
Yes
No
and ventilation fan watts are no greater than shown on CF -1 R.
Measured Watts =
3- ❑
®
Check' this box yes if a (CFM Q 50 Pa) is
Yes
No
greatothan the CFM @ 50 valres shown for an SLA of 1.5 on.
(if thisbox is checked no, mechanical ventilation is required.)
4. [
❑
Check Oft boot yes'5 r (CFM @ 50 Pa) is
Yes
No
less 11han the CFM Q 50 values shown for an SLA of 1.5 an
CF -1R, mechanical ventilation is wed and house pressure is
gra than minus 5 Pasch with all eoftud fans opt.
�
Pass iF Pass " Fal!
a. Yes in fine 1 and line 3, or
b. Yes in line 1 and line!, 2a, *and 2b, or
c. Yes in line 1 and Yes in line 4.
Otherwise fail.
131, tB undemigned. verify that ehe building envelope leakage meets Ste reqWrmeuts daitned for budding leakage reduction
below delimit amompfions as used for cc nplianpe an the CF -1R: This:is to certify that the above dnDgruosdc rest results sud
the work I peed amodated with the test(s) is is ooze wild the for coaWfince aediL [rIto truce
Ball provide the HERS provider a copy of the CF dR sgoed by the Tam employees or orb -cofactors certifying that
diagnostic testing and meet the regmemews fior owe aie&Lj
p
Test Performed Signature Date Testing Subcontractor (Co. Name) OR ,
Genual Contractor (Co. Nam)
COPY TO-'<Buildiug Department
HERS Provider (if applicable)
Building Owner at Ocaapancy
INSTALLATION CERTIFICATE (Page 6 of 8) CF -6R
S-dilm-
he
The following is an explanation of many of the input values requited on this form:
k_►il;[�Y4_i�
be am of Me
IFurnace: I Cas (including Liquefied ANroleum uses) or oil -sued central furnace & I
I Boiled: I Gas or od-tied bot'k r I
MzH=dhmw Paci2w5d central heatpump
� H Split ceetral heat pump,
RoomAeatPamp: Room heat pump
LgPkglleatPnmp: Lame packWd heath (>— 65,000 BWk output)
I I Elearlc resistmoc heating (fixed HSPF = 3.413); ndkM electric resisue I
(lined HSPF=3.55)
CEC Cuff" Mangy Dame elk Medd Number fi+om awe Cin approved applimxx directory.
0 of Idenfical System is for those syr with do sante cfficicuW, duct location, dudR-valae and cagy.
fiom applicable Common certified appy directory.
Dad (or Pipiog) Later is attic, aawl space, CVC aarvi space, dotted space, micandifioned she or noire.
Dura (or Pim R -Valve fi m. Directory ofCcrtified hmdation Maks www mammos data
HeafieWC4ding Load refer to Commission approved load calculation procedure.
�.... Heat/Cool'mg. Capacity fitmr the applicable Coon certified appliance directory. Note: location elevations over
2,000 ft above sea level require a deraft of output capacity (refer do marwifitchaves literature).
I I Imp p bed ackawdpump 2 65,000 Btaft ogwp Substittme BER for SEER I
when SEER is not available
Roo aAnCou& I Room air conditioner. Wmimmn SEW varies*
I ILarge packWd air c 2 65,000 Btuft otepu* Substitute MR fi I
SEER when SEER is wt availabk
IEvapDirect I valmcs: an =11 A duct iocatin atli ; duct i0sulation R -Value = 42 - I
Evapiadirect: lurid nd MWoutiv+e cook sysWax For, cue calculation purposes, filed I
values` SEER=13.0; duct =ate duct Rwahae =42
�:`t_LAWire in IIK"1:1;1 a"I r r;I tri ifi:'r';I Ar;7.",7Jir77T.�7!!�77.•��T7'l.rl'Iti�lfl�l�l
JttatUM 4, 2001
INSTALLATION CERTIFICATE (Page 7 of --CF-6R
Site Addna FemiltNumber
The following is anexplanation ofrnMy of the input values required on this form
W&M Humm-
WArMution &V!e! Refer to ReddoWd Mmud Ew mm gletm-&-
Sftmft& SWmlmd — SM* premure -based system6 no pauqs.
pipe bmisig
Pipe bm3bdm an all 314 -inch pipes
POUAIWF-
Point of MMM Water Recovery System
RecirdlRoCamumt
Rmcir=hdonbop with nDcouftds
RCcWr=.wr
Reciriadlafian loop with a tbm
PUCCi[VTOW.
PAChcohdan b)ap with UMPC=hw control
RcciFdrnn&+TOW
Rechiculation, bop with a timer and tmqmmum control.
I
RecirimMemand:
Rmirculation Imp with demand control
wwr H -COW TWO
Shmage Gas,OR or Electric
Hempump
Instantaneous Gas
Impstorapoas
Indirect Gas (Boit)
Fenestratim
InNeeded
any door wM more dw one sqm'e foot ofgJam
EMU
Yes
AMD=
No
20ft
No
No
Yes
No
No
No
No
Yes
No
NO
Yes
No
NO
No
No
Yes'
Yes
yes
No
Yes(AFUE),
No.
Yes
Fenestratim
Vrmkms. sliding &= docs, French &Ms. *yb*b, andenswindimm 1w,
any door wM more dw one sqm'e foot ofgJam
Opendor�
Slider, hbged. filed
U -Factor
hNNEW U-FactwmwAbe lem then oreqW to value fmm MI R
OR -
bmsftlled weigVed average Waftr for the 10181 finesk3tion ams is lea than
or equal to value fimm MIR
SHGQ
lm IaHW SHGC most be bm than or equal to value ftm CF -IR
OR
Inserted weighted SWC for 60 torsi Amcsftfm area is hm than or equal to
value ftm MIR
M
Aninkrim s6admg &-vwr, ovahan& or eatedw Aadum device is msmUW
ConsistcutwM&CMIR
Shading Dcvk&-
Include when, the buil ft complied using an gxgff&r, dlift device: woven
sunscru%,kawamd'sinscreen, bw sun angle smmm=n, joU.&wn avmin&
roll -down bfimb or slats (do not list bft mum), or an ovedmg (include depth
in f6d).
• 11
INSTALLATION CERTIFICATE (Page 8 of 8) CF -6R
i
Site Address Pumit Num
`-' The following is an explanation of ][68" of the input values required on the Diagnostic portion of this form (page 3 of 17:
TYPE ®F CREDIT � ih
I t
Refer to Residenfidl Manual Chapters 4 and 5 for more details:
+ Y
Reduced Duct Surftce Area:
Calculated as the outside area of dee duct Areas ninst be measured and
verified by a HERS rater
hacproved Duct Location:
Supply duct located in other than attic„ as verified by location of registers
(does met mpfw HERS 1aI v i)L
Cmc Le
Pr erre pan test readbW roust be less than 1.5 Pascal at a home pressure of
25 Pascal.
TXV (or Commission
Aeoess cover wgWmd to fimili ate verificafim Eligibility 1xaet' for
approved equivalentk
C approved egdmdat, if WficaW is required to be nzL
ReducaioreInfiftWim
a gyred without machanicml ventilatiaaopetaming. .
Mmbmical vanIffidion is required for very tight hoose conamum when
credits for infiltration reduch m using d C testing are being used for
achwvmg coke These very tight houses are defined as those whb SLA
of less than 15. The compliance docuntentation. (CF -1R) will coal the
gyred CEM t na vahae fioma blower door test at 50 Pascal pr+eswe
Ofirence dud rqresems this SIA of I.S. Mil v on is also
req�ed ifdw buUw dhows to design do budding too =e kcal
v and claims a credit for mon below an SLA of 3.0.. The
congdianoe documentation (Ch -1R) will contain the measured CFM target
value that represents this 3.0 SLA. if the bmldm I i s credit is a design for
m5ltedion'redactian ghat is at anM A of3.0 or higher, and do actual
measared'M A is 1.5 or greater, thea mechanical ventilation is not required.
If dee SLA in tis case vie below 1.5, &m mitiinfian (sacb as tical
vCutffidaa) world be required.
.Prima 4, 2001 '
.I
.I
• r
INSULATION CERZTMCATE ,SIC -1
Number and Street tty
T
County ;i Subdivision . Lot Number r,
T • _ _d•7_._-L_11•.�_�n
1. ROOF
U
Material ,
Brand Name
Thickness (inches) ii
Thermal Resistance (R -Value)
2. CEILING
Batt or Blanket Type a
Brand Name
Thickness (inches)
Thermal Resistance (R -Value)
Loose Fill Type
Brand
Contractor's min installed weight/W lb
Minimum thickness inches
Manufacturer's installed weight per square foot to achieve Thermal Resistance (R -Value) i
3. EXTERIOR WALL
- !I
Frame Type
A. Cavity Insulation f
,
Material
Brand Name
Thickness (inches)
Thermal Resistance (R -Value)
B . Exterior Foam Sheathing
Material
Brand Name
Thickness (inches)
Thermal Resistance (R -Value)
4. RAISED FLOOR
Material
Brand Name "
Thickness (inches)
Thermal Resistance (R -Value)
5. SLAB FLOOR/PERIMETER„
Material
Brand Name;
Thickness (inches) t
Thermal Resistance (R -Value)
Perimeter Insulation Depth (inches)
6. FOUNDATION WALL
Material
Brand Name
Thickness (inches) i
Thermal Resistance (R -Value)
(Declaration
I hereby certify that the above, insulation was installed in the building at the above location in conformance with the current
Energy Efficiency Standards for residential buildings (Title 24, Part 6, California Code of Regulations) as indicated on the
Certificate of Compliance, where applicable.
Item !#s Signature, Date
Installing Subcontractor (Co. Name) OR
h
General Contractor (Co. Name) OR Owner
Item #s Signature, Date
Installing Subcontractor (Co. Name) OR
General Contractor (Co. Name) OR Owner
—� !R
Item #s Signature, Date
r
Installing Subcontractor (Co. Name) OR l
General Contractor, (Co. Name) OR Owner 'f