05-5463 (MECH)P
'P.O. BOX 1504 .
y 78-495 CALLE TAMPICO
-' LA QUINTA, CALIFORNIA 92253
Application Number:05=LO:0.0.0.5.4.6,3_Zp�
Property Address: 54020 AVENIDA VILLA
APN: 774-224-010-9 - -000000-
Application description: MECHANICAL
Property Zoning: COVE RESIDENTIAL
Application valuation: 4097
•y 4
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
Owner:
r DRIVER RALPH M.
4a „f
Ry? 54020 AVENIDA VILLA
LA QUINTA, CA 92253
VOICE (760) 777-7012,
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date:
12/15/05
Contractor:
Applicant:Architect or Engineer:
PALM DESERT AIR CONDITIO
42081 BEACON HI.LL
PALM DESERT, CA 92211
(760)346-0677
LiC. No.:' 374937
l�
LICENSED CONTRACTOR'S DECLARATION -
WORKER'S COMPENSATION DECLARATION -
I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with
I hereby affirm under penalty of perjury one of the following declarations:
- Section 7000) of Division 3 of the Business and Professionals Code, and my License is in full force and effect._
I have and will maintain a certificate of consent to.self-insure for workers' compensation, as provided
- License Class: C20 License No.: 374937 -
for by Section 3700 of the Labor Code, for the performance of the work for which'this permit is
/1
Date:/2`Cntracwr,
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
- OWNER -BUILDER DECLARATION
�I
insurance carrier and policy number are: -
hereby affirm under penalty of perjury that I am exempt from the Contractor's State License Law for the
Carrier STATE FUND Policy Number 1795546
- • -,following reason (Sec. 7031.5, Business and Professions Code: Any city or county that requires a permit to - . -
_ I certify that, in the performance of the work for which this permit is issued, I shall not employ any
-construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the
person in any manner so as to become subject to the workers' compensation laws of California,
' permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractor's State
and agree that, if I should becomesubthe workers' compensation provisions of Section -
License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Codel or
th c'e
3700 of the Labor Code, •s twiply wi rovisions.
? that he or she is exempt therefromand 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):
ate: �Z" S"¢ Applicant; - - -
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
WARNING: FAILURE TO SECURE WORKERS OMPENSATION COV AGE IS UNLAWFUL, AND SHALL.
Contractors' State License Law does not apply to an owner of property who builds or improves thereon,
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
and who does the work himself.or herself through his or her own employees, provided that the
DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
improvements are not intended or offered for sale. If, however, the building or improvement is sold,within
SECTION 3706 OF THE LABOR.CODE, INTEREST, AND ATTORNEY'S FEES.
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.). - -
APPLICANT ACKNOWLEDGEMENT
(_) I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.
IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the
` 7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of -
conditions and restrictions set forth on this application.
property who builds or improves thereon, and who contracts for the projects with a contractor(s) licensed
1 . Each person upon whose behalf this application is made, each person at whose request and for
' pursuant to the Contractors' State License Law.l.
whose benefit work is performed under or pursuant to any permit issued as a result of this application,
• (_) I am exempt under Sec. ,'B.&P.C. for this reason -
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.
Date: Owner:
.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
_ CONSTRUCTION LENDING AGENCY_
- permit to cancellation.
I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the
I certify that I have read this application and state that the above information is correct. I agree to comply with all
work for which this permit is issued (Sec. 3097, Civ. C.).
city and county ordinances and state laws relating to building constru e - nd hereby rize representatives
'
of this county to enter• upon the above-mentioned property f ection pu
Lender's Name:
•
•7 C[`
ate: 2 X7-8 5 (Applicant or Agent):--
' '
ature
Lender's Address:
LQPERMIT
.. ..
Application Number 05-00005463
Permit MECHANICAL
Additional desc .
Permit Fee. 35.00
Plan Check
Fee
8.75
Issue Date
Valuation
0
Expiration Date,. 6/13/06
Qty Unit Charge Per:
Extension
BASE
FEE
15.00
1.0.0 11.0000 EA MECH
FLOOR FURNACE
11.00
-1.00- 9.0000 BA MBCII
----------------------------------------------------------------------------
APDL RDr,1ALT/ADD
9. 0 0
Special Notes and Comments•
REPLACE 5 TON FURNACE AND COIL -
Fee summary Charged
-------- -
Paid Credited
Due
----------------- 7 ---
Permit Fee Total 35.00.
---- -----
.00
----------
.00
35.00
Plan Check Total 8.75
.00
.00
8.75
Grand Total 43.75.
.00
.00
43.75 -
LQPERMIT
INSTALLATION CERTIFICATE ti: ,
(Page. 1 of 12) CF -6R
Site Address _ ,., Permit Number
Installation certificates (CF -6R) are required for each and every dwelling unit. When the installation of:measures that require
field verification and diagnostic testing is complete, the builder or the builder's subcontractor shall complete diagnostic
testing and the procedures specified in this section. When the installation is complete, the builder or the builder's
subcontractor shall complete the CF -6R (Installation Certificate), and keep it at the building site for review by the building
department. The builder also shall provide a copy of the Installation Certificate to the HERS rater for any measures requiring
field verification and diagnostic testing, per Section 10-103(a).
Distribution
CEC Certified Type
Heater Mfr Name & (Std, Point-
Type Model Number of -Use, etc)
If # of Rated Input
Recirculation, Identical (kW or Tank Volume
Control Type Systems Btu/hr)�(gallons)
External
Efficiency Standby Insulation
(EF, RE)2 Loss (%)2 R-value2
Date: r - l �- , G° :
1 . For small gas storage (rated input of less than or equal to 75,000 Btu/hr), electric resistance and teat pump water
heaters, list Energy Factor (EF). For large gas storage water heaters (rated input of greater than 75,000 Btu/hr), list
Recovery (RE), Thermal Efficiency, Standby Loss and Rated Input. For instantaneous gas water raeaters, list Thermal,
Efficiency and Rated Input.
2. R-12 external insulation is mandatory for storage water heaters with an energy factor of less'than 0. 58.
Kitchen Piping:
If indicated on the CF -1R, all hot water piping > 3/4 inches in diameter that runs, from the hot water source to the kitchen
fixtures is insulated.
Faucets & Shower Heads:
All faucets and showerheads installed are certified to the Energy Commission, pursuant to Title 24, Part 6, Section 111.
Central Water Heating in Buildings with Multiple Dwelling Units (required for prescriptive)
[]All hot water piping in main circulating loop is insulated to requirements of §1500)
❑Central hot water systems serving six or fewer dwelling units which have (1) less than 25' of distribution piping
outdoors; (2) zero distribution piping underground; (3) no recirculation pump; and (4) insulation on -distribution piping
that meets the requirements of Section 1500)
❑Central hot water systems serving more than 6 dwelling units - presence of either a time control or a time/temperature
control
✓ ❑ I, the undersigned, verify that equipment listed above my signature is: 1) the actual equJpment installed; 2)
equivalent to or more efficient than that specified in the certificate of compliance (Form CF -1R) submitted for compliance
with the Energy Efficiency Standards for residential buildings; and 3) equipment that meets or exceeds the appropriate
requirements for manufactured devices (from the Appliance Efficiency Regulations or Part 6), where applicable.
Installing Subcontractor (Co. Name) OR General
Contractor (Co. N caner
Signature:
Date: r - l �- , G° :
Copies to: BUILDING DEPARTMENT, HERS RATER (IF APPLICABLE) BUILDING OWNER AT OCCUPANCY
Residential Compliance Forms September 2005
INSTALLATION CERTIFICATE (Page 2 of 12) CF -6R
Site Address I Permit Number
An installation certificate is required to be posted at the building,site or made available for all appropriate inspections. (The
information provided on this form is required) After completion of final inspection, a copy must be pro.vided to the building
department (upon request) and the building owner at occupancy, per Section 10-103(a).
FENESTRATION/GLAZING:
ft
Item
Manufacturer/Brand
Name
(GROUP LIKE
RODU CTS)
Total
t Quantity of Area Ex-erior
Product U -factor Product SHGC # of Like Product Square Shading Device Comments/Location/
(5 CF -1 R value) 2 (5CF-1 R value)2 Panes (Optionao (OptionsFeet or Overhang Special Features
I
General Contractor (Co. Name) OR Owner
2.
OR Window Distributor
3.
Signature ' Date
Installing Subcontractor (Co. Name) Old
4.
General Contractor (Co. Name) OR Owner
5.
OR Window Distributor
6.
Signature Date '
Installing Subcontractor (Co. Name) Of,
7.
General Contractor (Co. Name) OR Owner
8.
OR Window Distributor
9.
10.
11.
12.
13.
14.
15.
Use values from a fenestration product's NFRC label. For fenestration products without an NFRC laael, 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 SHGC must be less thwi or equal to values
from CF -1R, or a shading device (exterior or overhang) is installed as specified on the CF -1R. Alternatively, installed
weighted average U -factors for the total fenestration area are less than or equal to values from CF -1F.. If using default table
SHGC values from § 116 identify whether tinted or not.
✓ ❑ I, the undersigned, verify that the fenestration/glazing listed above my signature: 1) is the actual fenestration
product installed; 2) is equivalent to or has a lower U -factor and lower SHGC than that specified in the certificate of
compliance (Form CF -1R) submitted for compliance with the Energy Efficiency Standards for residential buildings; and
3) the product meets or exceeds the appropriate requirements for manufactured devices (from Part 6), where applicable.
Item #s
Signature Date
Installing Subcontractor (Co. Name) OR
(if applicable)
General Contractor (Co. Name) OR Owner
OR Window Distributor
Item #s
Signature ' Date
Installing Subcontractor (Co. Name) Old
(if applicable)
General Contractor (Co. Name) OR Owner
OR Window Distributor
Item #s
Signature Date '
Installing Subcontractor (Co. Name) Of,
(if applicable)
General Contractor (Co. Name) OR Owner
OR Window Distributor
Copies to: Building Department, HERS Rater (if applicable) Building Owner at Occupancy
Residential Compliance Forms April 2005
An installation certificate is required to be posted at the building site or made available for all appropriate inspections. (The
information provided on this form is required) After completion of final inspection, a copy must be provided to the building
department (upon request) and the building owner at occupancy, per Section 10-103(a).
HVAC SYSTEMS:
Heating Equipment
Equip Type
(pkg. heat um
CEC Certified Mfr.
Name and Model
Number
# of
Identical
S stems>_CF-IR
Efficiencyt
(AFUE, etc.)
value)
Duct
Location
attic, etc.
Duct or
Piping
R -value
Heating
Load
Btu/hr
Heating
Capacity
Btu/hr
�=-
oG
a
Cooling Equipment
Equip Type
(pkg. heat um
CEC Certified Mfr.
Name and Model
Number
# of
Identical
Systems
Efficiency
(SEER or EER)
?-,CF-IR value)
Duct
Location
attic etc.
Duct
R -value
Cooling
Load
Btu/hr
Cooling
Capacity
Btu/hr
1. > symbol reads greater than or equal to what is indicated on the CF -IR value.
Include both SEER and EER if compliance credit for high EER air conditioner is claimed.
✓
1:111, the undersigned, verify that equipment listed above is: 1) is the actual equipment installed, 2) equivalent to or
more efficient than that specified in the certificate of compliance (Form CF -1R) submitted for compliance with the
Energy Efficiency Standards for residential buildings, and '3) equipment that meets or exceeds the appropriate
requirements for manufactured devices (from the Appliance Efficiency Regulations or Part 6), where applicable.
Installing Subcontractor (Co. Name) OR General
Contractor (Co. Name) OR Owner
Signature: Date:
Copies to: BUILDING DEPARTMENT, HERS RATER (IF APPLICABLE) BUILDING OWNER AT OCCUPANCY
Residential Compliance Forms April 2005
INSTALLATION CERTIFICATE (Page 4 of 12) CF -6R
Site Address o Permit Number
INSTALLER -COMPLIANCE STATEMENT FOR DUCT LEAKAGE
INSTALLER COMPLIANCE STATEMENT
The building was: ✓ ❑Tested at Final ✓ ❑ Tested at Rough -in
INSTALLER VISUAL INSPECTION AT FINAL CONSTRUCTION STAGE:
❑ Remove at least one supply and one return register, and verify that the spaces between the register boot and the interior
finishing wall are properly sealed.
❑ If the house rough -in duct leakage test was conducted without an air handler installed,' inspect the connection points
between the air handler and the supply and return plenums to verify that the connection points are p•-operly sealed.
❑ Inspect all joints to ensure that no cloth backed rubber adhesive duct tape is used
❑ New Distribution system is fully ducted (i.e., does not use building cavities as plenums or platforms returns in lieu of
ducts).
✓ ❑ DUCT LEAKAGE REDUCTION
Praredurec fnr field verirratian and diannnc/ir tactino nfair dictrihutinn vvctamc ara availahla in RAIL -M Annandir Rrd ?
NEW CONSTRUCTION:
„
Duct Pressurization Test Results (CFM @ 25 Pa)
Measured
Values
1
Enter Tested Leakage Flow in CFM:
Fan Flow: Calculated (Nominal: ✓ ❑ Cooling ✓ 0 Heating) or ✓ ❑ Measured
2
If Fan Flow is Calculated as 400 cfm/ton x number of tons or as 21.7 cfm/(kBtu/hr) x Heating
Capacity in Thousands of Btu/hr output, enter total calculated or measured fan flow in CFM her
L.
✓ ✓
3
Pass if Leakage Percentage<_ 6% for Final or:5 4% at Rough -in:
❑Pass ❑Fail
100 x Line # 1 / Line # 2
ALTERATIONS:
Duct System and/or HVAC Equipment Change -Out-',
4';:
Enter Tested Leakage Flow in CFM from Pre -Test of Existing Duct System Prior to Duct
j�=� t 'fit
System Alteration and/or Equipment Change -Out.
qG
CP
4^�
5
Enter Tested Leakage Flow in CFM from Final Test of New Duct System or Altered Duct
System for Duct System Alteration and/or Equipment Chan a -Out.,_
6
Enter Reduction in Leakage for Altered Duct System
Line # 4 Minus Line # 5 —(Only if Applicable)
7
Enter Tested Leakage Flow in CFM to Outside (Only if Applicable)
✓ ✓
Entire New Duct System - Pass if Leakage Percentage !< 6% for Final
❑ Pass ❑ Fail
8
100 x Line # 5 / Line # 2)11
TEST OR VERIFICATION STANDARDS: For Altered Duct System and/or HVAC Equipment Change-
✓
Out Use one of the following four Test or Verification Standards for compliance:
9
Pass if Leakage Percentage:5 15% [100 x [ (Line # 5) /-_ (Line # 2)]]
❑ Pass ❑ Fail
10
Pass if Leakage to Outside Percentage <_ 10% [100 x L (Line # 7) / (Line # 2)]]
❑ Pass 0 Fail
Pass if Leakage Reduction Percentage >_ 60% [100 x [—(Line # 6) / (Line # 4)]]
11
and Verification by Smoke Test and Visual Inspection
❑Pass ❑Fail
12
Pass if Sealing of all Accessible Leaks and Verification by Smoke Test and Visual Ins ection',:
,}
❑ Pass ❑
Pass if One of Lines # 9 through # 12 ass
a` w"h ;r1
❑ Pass Ow
✓ UI, the undersigned, verify that the above diagnostic test results were performed in conformance wiii the requirements for
compliance credit. I, the undersigned, also certify that the newly installed or retrofit Air -Distribution System Ducts, Plenums and
Fans comply with Mandatory requirements specified in Section 150 (m) of the 2005 Building Energy Efficiency standards.
Installing Subcontractor (Co. Name) OR General
Contractor (Co. Name) OR Owner
„
Signature:
Date:
Copies to: BUILDING DEPARTMENT, HERS RATER (IF APPLICABLE) BUILDING OWNER AT OCCUPANCY
Residential Compliance Forms
,September 2005
� l
INSTALLATION CERTIFICATE (Page- 5 of 12) CF -6R
Site Address 5�1_ RC20 Permit Number
✓ ❑ THERMOSTATIC EXPANSION VALVE (TXV)
Procedures for field verification of thermostatic expansion valves are available in RACM, Appendix PJ -
I/
!✓ ✓
Access is provided for inspection. The procedure shall
consist of visual verification that the TXV is installed on
✓ Va Yes 0 No the system and installation of the specific equipment ' ❑
shall be verified.
Yes is a pass I Pass I Fai;
✓ ❑ REFRIGERANT CHARGE MEASUREMENT
Verification for Required Refrigerant Charge and Adequate Airflow for Split System Space Cooling Systems without
ThPrmnctntir. FYnnminn VnlvPc
Outdoor Unit Serial #
OF
Location
OF
Outdoor Unit Make
OF
Outdoor Unit Model
OF
Cooling Capacity
Btu/hr
Date of Verification
OF
Date of Refrigerant Gauge Calibration
(must be checked monthly)
Date of Thermocouple Calibration
(must be checked monthly)
0
Standard Charge Measurement Procedure (outdoor air dry-bulb 55°F and above):
Procedures for Determining Refrigerant Charge using the Standard Method are available in RA CM, Appendix RD2.
Note: The system should be installed and charged in accordance with the manufacturer's specifications before starting this
procedure.
Measured Temperatures
Supply (evaporator leaving) air dry-bulb temperature (Tsupply, db)
OF
Return (evaporator entering) air dry-bulb temperature (Treturn, db)
OF
Return (evaporator entering) air wet -bulb temperature (Tretum, wb)
OF
Evaporator saturation temperature (Tevaporator, sat)
OF
Suction line temperature (Tsuction, db)
OF
Condenser (entering) air dry-bulb temperature (Tcondenser, db)
OF
iu erheat Charge Method Calculations for Refrigerant Charge
Actual Superheat = Tsuction, db — Tevaporator, sat OF
Target Superheat (from Table RD -2) OF
Actual Superheat — Target Superheat (System passes if between -5 and +5°F) °F
Temperature Split Method Calculations for Adequate Airflow
Solit Method Calculation is not necessary ifAdeounte Airflow credit is taken
Actual Temperature Split = T return, db Tsupply, db
OF
Target Temperature Split (from Table RD3)
OF
Actual Temperature Split Target Temperature Split (System passes if between -
3°F and +3°F or, upon remeasurement, if between -3°F and -100°F
OF
Residential Compliance Forms April 2005
a
Standard Charge Measurement Summary:
System shall pass both refrigerant charge and adequate airflow calculation criteria from the same
measurements. If corrective actions were taken, both criteria must be remeasured and recalculated.
✓ ❑ Yes ❑ Na r System Passes
Alternate Charge Measurement Procedure (outdoor air dry-bulb below 55 °F)
Note: The system should be installed and charged in accordance with the manufacturer's specifications and installer
verification shall be documented on CF -6R before starting this procedure. If outdoor air'dry-bulb is 55 °F or above, installer
shall use the Standard Charge Measure Procedure:
Procedures for Determining Refrigerant Charge using the Alternate Method are available in RA CM, Ab_ pendia RD3.
Wei h -In Charging Method for Refrigerant Charge "
Actual liquid line length: ft
Manufacturer's Standard liquid line length: ft
Difference (Actual - Standard): ft
Manufacturer's correction (ounces per foot) x difference in length = ounces
(+ = add) (- = remove)
t
Alternate Charge Measurement Summary:
System shall pass both refrigerant charge and adequate airflow calculation criteria from the same measurements. If
corrective actions were taken, both criteria must be remeasured and recalculated.
✓ ❑Yes ❑ No S stem Passes
MISCELLANEOUS CREDITS
✓ ❑ DIAGNOSTIC SUPPLY DUCT LOCATION, SURFACE AREA AND R -VALUE
Procedures for field verification and diagnostic lesling for this group compliance credits are available in RACM, Fppendix RC, RE & RH.
✓ ❑ LESS THAN 12 LINEAL FEET OF SUPPLY DUCT OUTSIDE OF CONDITIONED SPACE
COMPLIANCE CREDIT
✓ ❑Yes I ONo I Less than 12 lineal feet of supply duct outside of -conditioned space.
Yes to this compliance credit is a pass ✓ ❑ ?ass ✓ ❑Fail
✓ ❑ SUPPLY DUCTS LOCATED IN CONDITIONED SPACE COMPLIANCE CREDIT
✓ ❑ Yes 10 No I Ducts are located within the conditioned volume of building.
Yes to this compliance credit is a pass ✓ ❑ Pass ✓ ❑ Fail
Luct system Lestgn vermcatnon is requireu for a compuance crena for the touowmg:
1. Supply duct surface area reduction
2. Buried supply ducts on the ceiling
3. Deeply buried supply ducts
✓ ❑ DUCT SYSTEM DESIGN VERIFICATION
✓
❑ Yes
❑ No
Adequate airflow verified
✓
❑ Yes
❑ No
The duct system design plan meets the requirements specified in RACM, Appendix RE, Section
RE.4.2
✓
❑ Yes
❑ No
The duct system design plan exists on building plans
✓
❑ Yes
O No
Duct sizes, duct system layout and locations of supply & return registers match the duct system
design plan
Yes to all is a pass ✓ ❑ Pass ✓ ❑Fail
✓ ❑ SUPPLY DUCTS SURFACE AREA REDUCTION COMPLIANCE CREDIT
Attic
Crawl
Space
Basement
R-4.2
Deeply Duct Surface
Covered Covered Other Diameter Area
R-6.0
Surface
A. -ea
R-8.0
Surface
Area
❑
❑
❑
❑ ❑ ❑
Yes to ducts stem design, supply duct surface area reduction and this compliance credit is a pass
❑ Pass
❑
❑
❑
❑ ❑ ❑
❑
❑
❑
❑ ❑ ❑
❑
❑
❑
❑ ❑ ❑
❑
❑
❑
❑ ❑ ❑
❑
❑
❑
❑ ❑ ❑
❑
❑
❑
❑ ❑ ❑
Total Surface Area for Each R -Value =
✓ ❑
Yes 10
No latches Performance's CF -IR?
✓
Yes to all is a pass
❑ ?ass
❑ Fail
✓ O BURIED DUCTS ON THE CEILING COMPLIANCE CREDIT
✓ ❑ DEEPLY BURIED DUCTS COMPLIANCE CREDIT
✓
❑ Yes
❑ No
Buried Ducts on the Ceiling
✓
❑ Yes
❑ No
Verified High Insulation Installation Quality
✓
✓
Yes to ducts stem design, supply duct surface area reduction and this compliance credit is a pass
❑ Pass
1 O Fail
✓ ❑ DEEPLY BURIED DUCTS COMPLIANCE CREDIT
✓
❑ Yes
❑ No
Deeply Buried Ducts
✓
❑ Yes
❑ No
I Verified High Insulation Installation Quality
✓
✓
Yes to ducts stem design, supply duct surface area reduction and this compliance credit is a pass
❑Pass
1 O Fail
Copies to: BUILDING DEPARTMENT, HERS RATER (IF APPLICABLE) BUILDING OWNER AT OCCUPANCY
Residential Compliance Forms April 2005
✓❑ FAN WATT DRAW
Procedures or measuring the air handler watt draw are available in
✓ Method For Fan Watt Draw Measurement
❑ RE3.2.1 Portable Watt Meter Measurement
❑ RE3.2.2 Utilitv Revenue Meter Measurement
RE3.2.
Measured Fan Watt Draw
Measured Fan Flow enter total cfm from airflow verification
Enter results of Watts/cfm
❑ RE4.1.1 Diagnostic Fan Flow Using
Flow Capture Hood
❑ RE4.1.2 Diagnostic Fan Flow Using
✓ ❑ Yes
❑ No
Measured fan watt/cfm draw is equal to or lower than the
fan watt/cfm draw documented in CF -1R ❑
❑
✓
❑ Yes
Yes is a pass Pass
Fail
✓ ❑ ADEQUATE AIRFLOW VERIFICATION
Procedures for measuring, the airflow are available in RACM Annendix RE3. L
✓ Method For Airflow Measurement
✓
❑ Yes
❑ RE4.1.1 Diagnostic Fan Flow Using
Flow Capture Hood
❑ RE4.1.2 Diagnostic Fan Flow Using
Plenum Pressure Matching
❑ RE4.1.3 Diagnostic Fan Flow Using
Flow Grid Measurement
❑ Yes ❑ No Duct design exists on plans
✓
❑ Yes
❑ No
4
Measured Airflow:
❑ Yes
❑ No
5
✓
Rated Tons cfm/ton
❑ No
If the cooling capacities of installed systems are > than maximum ✓ ✓
cooling capacity in the CF -1R, then the electrical input for the
installed systems must be <_ to electrical input in the CF -1R. ❑ ❑
Yes to 1, 2, and 3; and Yes to either 4 or 5 is a pass
✓ ✓
✓ ❑ Yes ❑ No Measured airflow is greater than the criteria in Table RE -2
Yes is a pass
Pass
I Fail
✓ ❑ MAXIMUM COOLING CAPACITY
Procedures for determining maximum cooling load capacity are available in RA CM. Aooendix RF3.
Watts
cfm
Watts/cfm
Total cfm
cfm/ton
1
✓
❑ Yes
❑ No
Adequate airflow verified (see adequate airflow credit)
Refrigerant charge or TXV
Duct leakage reduction credit verified
Cooling capacities of installed systems are <_ to maximum cooling
capacity indicated on the Performance's CF -1R and RF -3.
2
✓
❑ Yes
❑ No
3
✓
❑ Yes
❑ No
4
✓
❑ Yes
❑ No
5
✓
❑ Yes
❑ No
If the cooling capacities of installed systems are > than maximum ✓ ✓
cooling capacity in the CF -1R, then the electrical input for the
installed systems must be <_ to electrical input in the CF -1R. ❑ ❑
Yes to 1, 2, and 3; and Yes to either 4 or 5 is a pass
Pass
I Fail
✓❑ HIGH EER AIR CONDITIONER
Procedures or veri cation are available in RACM, Appendix Rf.
1 ✓ ❑ Yes ❑ No I EER values of installed systems match the CF -1R
2 ✓ ❑ Yes ❑ No Fors lits stem, indoor coil is matched to outdoor coil
3 ❑ Yes ❑ No Time Delay Relay Verified (If Required)
Yes to 1 and 2; and 3 If Re vire
C
❑ 1 ❑
isapssl Pass I Fail
Installing Subcontractor (Co. Name) OR General
Contractor (Co. Name) OR Owner
Signature: Date:
spies to: BUILDING DEPARTMENT, HERS RATER (IF APPLICABLE) BUILDING OWNER AT OCCUPANCY
Residential Compliance Forms April 2005
INSTALLATION CERTIFICATE (Page 9 of 12) CF -
Site Address ' � r Permit Number
An installation certificate is required to be posted at the building site or made available for all appropriate inspections. (The
information provided on this form is required) After completion of final inspection, a copy, must be provided to the building
department (upon request) and the building owner at occupancy, per Section 10-103(a).
BUILDING ENVELOPE LEAKAGE DIAGNOSTICS,
✓ ❑ ENVELOPE SEALING INFILTRATION. REDUCTION
Procedures for field verification and diagnostic testing of envelope leakage are available in RACM, Appendix RC
Diagnostic Testing Results
✓
✓
Building Envelope Leakage (CFM @ 50 Pa) as measured by Rater:
1
❑
❑
Measured envelope leakage less than or equal to the required level from
Yes
No
CF -1R?
❑
❑
2.
Is Mechanical Ventilation shown as required ori the CF -1R?
Yes
No
❑
❑
If Mechanical Ventilation is required on the CF -1R (`Yes' in linen), has it
2a
Yes
No
been installed? '
❑
❑
Check this box `yes' if mechanical ventilation is required (`Yes' in line 2)'
2b.
and ventilation fan watts are no greater than shown on CF -1R.
Yes
No
Measured Watts =
❑
❑
Check this box "yes" if measured building infiltration (CFM @ 50 Pa) is
3.'
greater than the CFM @ 50 values shown for an SLA of 1.5 on CF -1R
Yes
No
If this box is checked no, mechanical ventilation is required.)
Check this box "yes" if measured building infiltration (CFM @ 50 Pa) is
4
❑
❑
less than the CFM @ 50 values shown for an SLA of 1.5 on CF -1R,
Yes
No
mechanical ventilation is installed and house pressure is greater than minus
5 Pascal with all exhaust fans operating. .
Pass if:
a. Yes in line 1 and line 3, or
✓
✓
b. Yes in line 1 and line2, 2a, and 2b, or
c. Yes in line 1 and Yes in line 4.
❑
❑
Otherwise fail.
Pass
Fail
✓ ❑ I, the undersigned, verify that the building envelope leakage meets the requirements claimed for building leakage
reduction below default assumptions as used for compliance on the CF -1R. This is to certify that the above diagnostic test
results and the work I performed associated with the'test(s) is in conformance with the requirements for compliance credit.
(The builder shall provide the HERS provider a copy of the CF -6R signed by the builder employees or subcontractors
certifying that diagnostic testing and installation meet the requirements for compliance credit.)
Test Performed
Installing Subcontractor (Co. Name) OR General
Contractor (Co. Name) OR Owner
Signature:
Date:
Copies to: BUILDING DEPARTMENT, HERS RATER (IF APPLICABLE), BUILDING OWNER AT OCCUPANCY
Residential Compliance Forms
April 2005
Insulation Installation Quality Certificate
✓ ❑ Description of Insulation, (CF -611, formerly IC -1) signed by the installer stating: insulation manufacturer's name,
material identification, installed R -values, and for loose -fill insulation: minimum weight per square foot and minimum
inches
✓ ❑ Installation meets all applicable requirements as specified in the High Quality Insulation Installation Procedures
.(ACM, Appendix RH)
✓ FLOOR
❑
Yes
❑
No
❑
NA
All floor joist cavity insulation installed to uniformly fit the cavity side-to-side and end-to-end
❑
Yes
O
No
❑
NA
Insulation in contact with the subfloor or rim joists insulated
❑
Yes
❑
1 No
❑
NA
Insulation properly supported to avoid gaps, voids, and compression
✓ WALLS
❑
❑
❑
Wall stud cavities caulked or foamed to provide an air tight envelope
Yes
No
NA
❑
Yes
❑
No
0
NA
Wall stud cavity insulation uniformly fills the cavity side-to-side, top -to -bottom, and front -to -back
❑
❑
❑
No gaps
Yes
No
NA
p
Yes
❑
No
❑
NA
No voids over 3/4" deep or more than 10% of the batt surface area.
❑
❑.
❑
Hard to access wall stud cavities such as; corner channels, wall intersections, :and behind
Yes
No..
NA
tub/shower enclosures insulated to proper R -Value
❑
❑
❑
Small spaces filled
Yes
No
NA
❑
❑
❑
Rim joists insulated
Yes
No
NA
❑
❑
❑
Loose fill wall insulation meets or exceeds manufacturer's minimum weight -per -square -foot
Yes
No
NA
requirement
✓ ROOF/CEILING PREPARATION
❑
Yes
❑
No
❑
NA
All draft stops in place to form a continuous ceiling and wall air barrier
❑
Yes
❑
No
❑
NA
All drops covered with hard covers
Yes
❑
I No
❑
NA
All draft stops and hard covers caulked or foamed to provide an air tight enve`ope
❑
❑
❑
All recessed light fixtures IC and air tight (AT) rated and sealed with a gasket or caulk between the
Yes
No
NA
housing and the ceiling
❑
Yes
❑
No
p
NA
Floor cavities on multiple -story buildings have air tight draft stops to all adjoining attics.
❑
Yes
❑
No
❑
NA
Eave vents prepared for blown insulation - maintain net free -ventilation area
❑
Yes
❑
No
❑
NA
Knee walls insulated or prepared for blown insulation
❑
Yes
❑
No
❑
NA
Area under equipment platforms and cat -walks insulated or accessible for blown insulation
❑
❑
❑
Attic rulers installed
Yes
No
NA
Residential Compliance Forms April 2005
✓ ROOF/CEILING BATTS
DECLARATION
✓ ❑ I hereby certify that the installation meets all applicable requirements as specified in the Insulation Installation
Procedures.
Installing Subcontractor (Co. Name) OR General
Contractor (Co. Name) OR Owner
Signature: Date:
Copies to: BUILDING DEPARTMENT, HERS RATER (IF APPLICABLE), BUILDING OWNER AT OCCUPANCY
Residential Compliance Forms April 2005
Yes
No
NA
No gaps
❑
❑
O
Yes
No
NA
No voids over 3/< in. deep or more than 10% of the batt surface area. '
Yes
No
NA
Insulation in contact with the air -barrier
Yes
No
NA
Recessed light fixtures covered
❑
❑
❑
Net free -ventilation area maintained at eave vents
Yes
No
I NA
✓ ROOF/CEILING LOOSE -FILL
❑
❑
❑
Yes
No
NA
Insulation uniformly covers the entire ceiling (or roof) area from the outside of all exterior walls.
❑
❑
❑
Yes
No
NA
Baffles installed at eaves vents or soffit vents- maintain net free -ventilation area of eave vent
❑
❑
❑
Yes
No
NA
Attic access insulated
❑
❑
❑
Yes
No
NA
Recessed light fixtures covered
❑
❑
❑
Yes
No
NA
Insulation at proper depth — insulation rulers visible and indicating proper depth and R -value
❑
❑
❑
Loose -fill insulation meets or exceeds manufacturer's minimum weight and d ickness requirements
Yes
No
NA
for the target R -value. Target R -value . Manufacturer's minimum required
weight for the target R -value (pounds -per -square -foot). Manufacturer's
minimum required thickness at time of installation Mani facturer's minimum
required settled thickness . Note: To receive compliance credit the KERS rater
shall verb that the manufacturer's minimum weight and thickness has been achieved for the target
R -value. CF -6R only)
DECLARATION
✓ ❑ I hereby certify that the installation meets all applicable requirements as specified in the Insulation Installation
Procedures.
Installing Subcontractor (Co. Name) OR General
Contractor (Co. Name) OR Owner
Signature: Date:
Copies to: BUILDING DEPARTMENT, HERS RATER (IF APPLICABLE), BUILDING OWNER AT OCCUPANCY
Residential Compliance Forms April 2005
INSTALLATION CERTIFICATE (Page 1.2 of 12) CF -6R
Site Address —
Permit Number_
County Subdivision
'Lot Number
Description of Insulation (Formerly IC -1 Form)
Signature Date
1. RAISED FLOOR
Item #s
Material
Brand Name
Thickness (inches) -
Thermal Resistance (R -Value)
2. SLAB FLOORIP_ERIMETER
Material
Brand Name
Thickness (inches)
Thermal Resistance (R -Value)
Perimeter Insulation Depth (inches)
(if applicable)
3. EXTERIOR WALL
General Contractor (Co. Name) OR Owner
Frame Type
A. Cavity Insulation
Material
Brand Name ,
Thickness (inches)
Thermal Resistance (R -Value)
B . Exterior Foam Sheathing
Material
Brand Name
Thickness (inches)
Thermal Resistance .(R -Value)
4., FOUNDATION WALL
Material
Brand Name
Thickness (inches)
Thermal Resistance (R -Value)
5. -. CEILING
Batt or Blanket Type
Brand Name
Thickness (inches)
Thermal Resistance (R -Value)
Loose Fill Type
Brand
Contractor's min installed weight/ft' lb
Minimum thickness inches
Manufacturer's installed weight per square foot to achieve Thermal Resistance (R -Value)
6. ROOF
Material
Brand Name
Thickness (inches)
Thermal Resistance (R -Value)
Declaration
✓ ❑ I hereby certify that the above insulation was installed in the building at the above location in conformance with the
current Energy Efficiency Standards for residential buildings (Title 24, Part 6, California Code of Regulations) as indicated
on the Certificate of Compliance, where applicable.
Item #s
(if applicable)
Signature Date
Installing Subcontractor (Co. Name) OR
General Contractor (Co. Name) OR Owner
OR Window Distributor
Item #s
Signature Date
Installing Subcontractor (Co. Name) DR
(if applicable)
General Contractor (Co: Name) OR Owner
OR Window Distributor
Item #s
Signature Date
Installing Subcontractor (Co. Name) DR
(if applicable)
General Contractor (Co. Name) OR Owner
OR Window Distributor
Residential Compliance Forms April 2005
r
,CERTIFICATE OF COMPLIANCE: RESIDENTIAL (Page 1 of 5), CF -1R
Pr • ct • le
Date
Bu�lchjg Perniii #40 :
5• �,,a_ 1
MR ti
Pro' Addr s
Roof Radiant
Barrier
Installed
Yes or No
Location '
Comments
(attic, garage, '
ical, etc. '
11&19 heck•/ Bate ` °
'.
Documentation Author
Telephone
Compliance Method (Prescriptive)
Climate Zone
FieldCheck/ Batee
r� ` '� , ,
�Enforcement� enc" Use -hl." 7,
v" ❑ Alternative Component Package Method: (check one) CD D (Alternaaive)
Package C and Package D choices require HERS rater field veri i�n and/or diagnostic tes�ing (see CF -1R page 3)
For Package D Alternative see Appendix B Table 151-C Footnotes 7-14
. r
GENERAL INFORMATION
Total Conditioned Floor Area (CFA)
Average Ceiling Height: ft :.
Maximum Allowed West Facing Fenestration Products Per Table 151-B or 151-C ---- (5% X CFA) ft'
Maximum Allowed Total Fenestration Products Per Table 151-B or 151-C ----(20% X CFA) ft2
t.
✓ ❑ Building Type: (check one or more) Single Family Multifamily . Addition Alteration
(If adding fenestration fill out WS -4R, Fenestration Maximum Allowed Area Worksheet and see Section 8.3.2
for Additions and 8.3.3 for Alterations.)
Number of Stories: ' Number of Dwelling Units:
Floor Construction Type: Slab/Raised Floor (circle one or both)
Front Orientation: North / South / East / West / All Orientations (input front orientatioi in degrees from True North
and circle one).
✓ ❑ RADIANT BARRIER (required in climate zones 2, 4, 8-15)
OPAQUE SURFACES INCLUDING OPAQUE DOORS
Component
Type (Wall,
Roof, Floor,
Slab Edge,
Doors)
Frame
Type
(Wood or
Cavity
Insulation
R -Value
Assembly U -
factor (for wood,
Continuous metal frame and
Insulation mass
R -Value assemblies)'
Joint
Appendix
IV
Reference
Roof Radiant
Barrier
Installed
Yes or No
Location '
Comments
(attic, garage, '
ical, etc. '
1) See Joint Appendix -IV in Section 1V.2, 1V.3 and 1VA, which is the basis for the U -tactor criterial. U -tactors can not exceed
prescriptive value to show equivalence to R -values.
Residential Compliance Forms ' April 2005.
CERTIFICATE OF COMPLIANCE: RESIDENTIAL (Page 3 of 5) CF -1R
Proiect Title i/ L°ate MAT -
SEALED DUCTS and TXVs (or Alternative Measures)
A signed CF -4R Form must be provided to the building department for each home for which the following. are
reAuired.
I✓ iI .
OR
❑ Alternative to Sealed Ducts and Refrigerant Charge /TXVs (See Package D Alternative Package Features for
Proiect Climate Zone in the RM Appendix B Table 151-C, Footnotes 7-14.
OR
For additions and alterations, duct systems that are not documented to have been previously
❑ sealed as confirmed through field verification and diagnostic testing in accordance with procedures in the
Residential ACM Manual and duct systems with more than 40 linear feet in unconditioned
spaces shall meet the requirements of Section 150(m) and duct insulation requirements of Package D.
WATER HEATING SYSTEMS
Sealed Ducts all climate zones(Installer testing and certification and HERS rater field Ferification required.)
0/
TXVs, readily accessible (climate zones 2 and 8-15 only)
Installer testing and certification and HERS Rater field verification required.)
❑
Refrigerant Charge (climate zones 2 and 8-15 only) (Installer testing and certification and HERS Rater field
❑
verification required.)
OR
❑ Alternative to Sealed Ducts and Refrigerant Charge /TXVs (See Package D Alternative Package Features for
Proiect Climate Zone in the RM Appendix B Table 151-C, Footnotes 7-14.
OR
For additions and alterations, duct systems that are not documented to have been previously
❑ sealed as confirmed through field verification and diagnostic testing in accordance with procedures in the
Residential ACM Manual and duct systems with more than 40 linear feet in unconditioned
spaces shall meet the requirements of Section 150(m) and duct insulation requirements of Package D.
WATER HEATING SYSTEMS
Svstems serving single dwelling units
Rated
Input'
Water Heater Distribution Number (kw or
lVpe/Fuel Type Type in System Btu/hr(gallons)
Check box if system meets criteria of a "Standard" system. Standard system is one gas--'ired water heater per
❑
dwelling unit. If the water heater is a storage type, 50 gallons is the maximum capacity :and recirculation system is
not allowed.
❑
Check box when using Preapproved Alternative Water Heating table, Table 5-4 in Chap-.er 5 in the Residential
Manual. No water heating calculations are required, and the system complies automatically.
Check box if system does not meet criteria of "Standard" system, and does not comply With the Preapproved
❑
Alternative Water Heating table. In this case, the Performance Method must be used and must be included in the
submittal.
box to verify that a time control is required for a recirculating system pump for a system serving multiple
❑
ICheck
units
Svstems serving single dwelling units
Rated
Input'
Water Heater Distribution Number (kw or
lVpe/Fuel Type Type in System Btu/hr(gallons)
Energy
Tank Factor' or
Capacity The: -mal
Efficient
Tank
External
Standby Insulation
Loss % R -Value
Tank
External
Insulation
R -Value
ti
System serving multi le dwelling units
Wter Heater
VT e
Rated Energy
Input' Tank Factor' or
Distribution Number (kw or Capacity. Thermal
Type in System Btu/hr(gallons) Efficient
Standby
Loss %
Tank
External
Insulation
R -Value
ti
1) For small gas storage water heaters (rated inputs of less than or equal to 75,000 Btu/hr), electric resistance, and
heat pump water heaters, list Energy Factor. For large gas storage water heaters (rated input of greater than 75,000
Btu/hr), list Rated Input, Recovery Efficiency, Thermal Efficiency and Standby Loss. For in.atantaneous gas water
heaters, list Rated Input and Thermal Efficiencies.
Pipe Insulation (kitchen lines >_ 3/4 inches) All hot water pipes from the heating source qo the kitchen fixtures,
that are 3/4 inches or greater in diameter shall be thermally insulated as specified by Section 150 0) 2 A or 150 0) 2
B.
Residential Compliance Forms April 2005
` CERTIFICATE OF COMPLIANCE: RESIDENTIAL (Page 2 of 5) CF -1R
Project Title Date ,l�t
a
FENESTRATION PRODUCTS — U -FACTOR AND SHGC
✓ ❑ FENESTRATION MAXIMUM ALLOWED AREA WORKSHEET WS -4R —must be included for New
Construction, Additions and Alterations.
Fenestration
#/Type/Pos. -
(Front, Left,
Rear, Right;
Skylight)
Orien-
tation,
N, S, E,
W'(ft)
Area U -factor
U-factor2 Source SHGC°
Exterior
Shading/Overhangs6•'
SHGC ✓ box if WS -3R is
Sources included
Aw
13
❑
13
13
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 §151(f)3C and in Section 3.2.3 of the Resid•:ntial Manual
2) Enter values in this column are either NFRC Rated value or from Standards default Table 116A.
3) Indicate source either from NFRC or Table I I6A,
• .4) Enter.values in this column from NFRC or from Standards Default Table 116B or adjusted SHGC from WS -3R.
5) Indicate source either from NFRC or Table 116B.
6) Shading Devices are defined in Table 3-3 in the Residential Manual and see WS -3R to calculate Exterior Shading
devices.
7) See Section 3.2.4 in the Residential Manual.
HVAC SYSTEMS
+ 1
Heating Equipment Minimum Distribution
Type and Capacity
fumace heat pump,boiler, etc.
Efficiency
AFUE or HSPF
Type and Location
ducts attic, etc.
Duct or Piping .The-mostat Configuration
R -Value Type (Split or package)
Aw
Cooling Equipment
Type and Capacity Minimum
(A/C, heat pump, evap. Efficiency Duct Location Duct Thermo_ stet Configuration
cooling) (SEER or EER' attic, etc. R -Value Type s lit or- acka e
.t r
CERTIFICATE OF COMPLIANCE: RESIDENTIAL (Page 4 of 5) CF -IR
Project Title Q Date /
SPECIAL FEATURES NOT REQUIRING HERS VERIFICATION (add extra sheets if necessary)
Indi ate which special features are part of this project. The list below represents special features relevant to the Prescriptive
�✓
Feature
Required Forms if applicable)
Description
❑
Metal Framed Walls.
CF -1R
❑
Radiant Barriers
CF -1R
❑
Exterior Shades
WS -4R
N/A; Performance Calculation
❑
Cool Roof
Required., Attach CR_ RC Label to
Forms.
Dedicated Hydronic Heating-
Performance Calculation
❑
System
Required; Attach Run to Forms.
Performance Calculation
❑
Combined Hydronic System
Required; Attach Run to Forms.
N/A; Performance Calculation
❑
Gas Cooling
Required.
❑
Buried Ducts
N/A; Indicate on building plans.
See Section 5.6.2 Distribution
❑
Kitchen Pipe Insulation
Systems in Residential Manual.
See Table 5-13 or use
❑
Multiple Water Heaters Per
Performance Calculation and
Dwelling Unit
attach Run to Forms.
Central Water Heating System
Performance Calculation and
❑
Serving Multiple Dwellings
attach Run to Forms.
❑
Non-NAECA Large Water
CF -1R
Heater
See Table 5-13 or use
❑
Indirect Water Heater
Performance Calculation and
attach Run to Forms
See Table 5-13 or use
❑
Instantaneous"Gas•Water Heater
Performance Calculation and
attach Run to Forms
See Table 5-13 or use
❑
Solar Water Heating System
Performance Calculation and
attach Run to Forms
Performance Calculation and
❑
Wood Stove Boiler
attach Run to Forms
SPECIAL FEATURES REQUIRING HERS RATER VERIFICATION
I.AA o..Mo eL.<otc ;f ......... N T—G,ntP to the TaFRC Rarer which crPditc are nart of thin nmiect and need verification.
✓ Feature Required Forms if applicable) Dmcri tion
Duct Sealing CF -6R part .4 of 12
❑ Refrigerant Charge CF -6R part 5 of 12
Thermostatic Expansion Valve CF -6R part 6 of 12
Residential Compliance Forms
September 2005
is
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:.r, ' `i�' CERTIFICATE OF :COMPLIANCE:; RESIDENTIAL' (Page 5 of 5 r `
C
E F_ 1R
? * I - Date , ; . r t > t • , , .t
Project Title ,:t,t'
t1
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r".COMPLIANCE STATEMENT ,t 13;*~h'as
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+" {:.. ia'fi h` f �' ' a. `'S''- ,F•• _Y - .J p `.,• .y.• (,„, - Y k g.','+t. '
+ , This certificate of compliance.lists the building features andspecifications needed to comply wrtli Title r `
24 Parts `Land 6 of the'California Code of Regulations, and the administrative: regul ations to implement
"Ahem. This certificate has been signed by the individual with overall design responsibility ,Thew'
-Y t'q
undersigned recognizes that compliance using -duct design, duct sealing:ve �ification,of refrigerant charge .4 }
+• .• r 3 • s W i
and TXV§,7 insulation'installation quality;; and building envelope sealing req 6ire^mstalI r testing and,-, r ti►
certification and field verificationtliy an approved HERS rater , f �� {t
ra a.. ... '"" i`,. �'r•
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t
` Desiner or Owner.(ver Business and Professions Code), Documentati"17 tithor'
Name 1 n t s r ', r r' , ''
`'
Name
awl
.
Title/Firm r,� "" q: ✓ a` , ' 3, ; _ r r t
Title/Firm
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Address , i,.r&,= r a ,. , 1
Address:,
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Telephoner r b n , 4 .t
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.�J•,,..r7',,..'tom 1,
7,:=Gv
.Mr7 fr.• ,e,�f t s. .t:`' . ,x
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Bin #
City of La Quinta
Building U Safety Division
P.O. Box. 1504, 78-495 Calle Tampico
La Quinta, CA 92253 -.(760) 777-.7012
Building Permit Application and Tracking Sheet .
Permit #
Project Address: � jLf JF—q) [VA 111 /—�-f't
Owner's Name:
A. P. Number:
Address: or-tf6 0ao
Legal Description:
City, ST, Zip:
Contractor: GJ zT >�/�
Telephone: 7L,0- 777' i 5 LtO
Address: � <06 jn_
L_Z--
Project Description: f`E' Li e yl 75 C �
City, ST, Zip: -19�VA t✓19 12-a If
l!fo I L,
Telephone: c—
State Lic. # City Lic. #:
Arch., Engr., Designer:
Address:
City, ST, Zip:
Telephone:
State Lic. #:
Name of Contact Person: L y`
Construction Type: Occupancy:
Project type (circle one): New Add'n Alter Repair Demo
Sq. Ft.: # Stories: # Units:
Telephone # of Contact Person: ? D - - . C9 6
Estimated Value of Project.
APPLICANT: DO NOT WRITE BELOW THIS LINE
#
Submittal
Rec;'d
Recd
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 Check Balance
Energy Calcs.
Plans picked up
Construction
Flood plain plan
Plans resubmitted
'Mechanical M
Grading. plan
2na Review, ready for corrections/issue
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
Called Contact Person
A.I.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees
Total Permit Fees
COACHELLA VALLEY WATER DISTRICT
4:
CASH RECEIPT DETAIL
L1 705
Received From: CN R t5r%�
L Im
Alk, _:5(V
' Date:
Y
Address: C'�'%'��
11`�/GC_i1
111 /�l'fiG- CA -9'1
.
Account No.
Lots)Tact
.��l7 �- -
Service Address
1
/ L CA G.A. Cod---
od-Meter(s)
Meter(s)
$
❑ Service(s)
I:
❑ Backflow(s)
❑ House Lateral(s)
ii
❑ DetectorCheck(s)
❑ Meter Surcharge
anitatlon Capacity Charge
�9Z5
❑ W.S.B.F.C.
❑ Temporary Construction Meter
❑ Turn on Charge
❑ Uncollected Account - Name
t
❑ Inspection Fee - Tract -.
Fee -
❑ Plan Check Fees Water I Sewer -
~
1
-Tract -
❑ Bond Payment - A.D. - Bond
{
Assmt.
i
❑ Customer Deposit
❑ Other
TOTAL'
$
f,
ar
Remks:
`
s
`
t
•
❑ Copy to:
Cash
Water Service
I.
Check J�
i'
Money
Cashier
Order
CVV11D-038 (11189)