06-2878 (MECH)TWIf 4
P.O. BOX 1504,' ^' VOICE (760) 777-7012
78-495 CALLE TAMPICO FAX (760) 777-7011
LA QUINTA, CALIFORNIA 92253 BUILDING & SAFETY DEPARTMENT INSPECTIONS (760) 777-7153
BUILDING PERMIT
- -8/02/0
Date: 6 .
_ � D
Application Number. 06 00002878 Owner.
Property Address: 78420 VIA SEVILLA LUCERO RICHARD
APN: 604-211-003-24 -23971 - 78420 VIA SEVILLA
Application description: MECHANICAL - LA QUINTA, CA 92253
Property Zoning: LOW DENSITY RESIDENTIAL
Application valuation: 1000
Applicant: Architect or Engineer:
`��'� CS\
----------------------_---- - - - - -- =- ----
LICENSED CONTRACTOR'S DECLARATIO I
-hereby affirm under penalty of perjury that I am licensed under provisions of Chapter ncing
Section 7000) of Division 3 of the Business and Professionals Code, and my License is in effect.
License Class: C20 -C10 License No.: 6936
I Dat,9&6A6_ Contractor: . .
OWNER -BUILDER DE ATION
I hereby affirm under penalty of perjury that I am exempt from the Co ctor's State License Law for the
following reason (Sec. 7031.5, Business and Professions Code: Any city or county that requires a permit to
construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the
permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractor's State
License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by
any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).:.
(_ 1 I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and
the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The
Contractors' State License Law does not apply to an owner of property who builds or improves thereon,
and who does the work himself or herself through his or her own employees, provided that the
'l improvements are not intended or offered for sale. If, however, the building or improvement is sold within
one year of completion, the owner -builder will have the burden of proving that he or she did not build or
improve for the purpose of sale.).
(_ 1 I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.
7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of
property who builds or improves thereon, and who contracts for the projects with a contractors) licensed
pursuant to the Contractors' State License Law.). .
(_ 1 I am exempt under Sec. , B.&P.C. for this reason
Date: Owner: '
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the
work for which this permit is issued (Sec. 3097, Civ. C.).
Lender's Name:
Lender's Address:
LQPERMIT
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
_ I have and will maintain a certificate of consent to self -insure for workers' compensation,as provided
for by Section 3700 of the Labor Code, for the performance of the work for which this permit is
issued.
I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor
Code, for the performance of the work for which this permit is issued. My workers' compensation
insurance carrier and policy number are:
Carrier STATE FUND Policy Number 0004779-2006
I certify that, in the performance of the work for which this permit is issued, I shall not employ any
person in any manner so as to become subject to the workers' compensation laws of California,
and agree that, if I should become subject to the wor rs' compensation provisions of Section
3700 of the Labor Code, I s all forthwith comply w' those provisions.
-Datlo Applicant:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION ERAGE IS UNLAWFUL, AND SHALL
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL F NES UP TO ONE HUNDRED THOUSAND
DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
APPLICANT ACKNOWLEDGEMENT
IMPORTANT Application is hereby made to the Director of Building and.Safety for a permit subject to the
conditions and restrictions set forth on this application. '
1. Each person upon whose behalf this application is made, each person at whose request and for
whose benefit work is performed under or pursuant to any permit issued as a result of this application,
the owner, and the applicant, each agrees to, and shall defend, indemnify and hold harmless the City
of La Quinta, its officers, agents and employees for any act or omission related to the work being
performed under or following issuance of this permit.
-2. Any permit issued as a result of this application becomes null and void if work is not commenced.
within 180 days from date of issuance of such permit, or cessation of work for 180 days will subject
permit to cancellation. .
I certify that I have read this application and state that the above information is correct. I agree to comply with all
city and county ordinances and state laws relating to building construction, and hereby authorize representatives
of this count to enter upon the above-mentioned property for in paction purposes. '
DattT�'JJ Signature (Applicant or Agent):
I �
Contractor:
CAVANAUGH ELECTRIC
83231 HIGHWAY 111
INDIO, CA92201
`t
(760)347-3608.
Lic. No.: 286936
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
_ I have and will maintain a certificate of consent to self -insure for workers' compensation,as provided
for by Section 3700 of the Labor Code, for the performance of the work for which this permit is
issued.
I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor
Code, for the performance of the work for which this permit is issued. My workers' compensation
insurance carrier and policy number are:
Carrier STATE FUND Policy Number 0004779-2006
I certify that, in the performance of the work for which this permit is issued, I shall not employ any
person in any manner so as to become subject to the workers' compensation laws of California,
and agree that, if I should become subject to the wor rs' compensation provisions of Section
3700 of the Labor Code, I s all forthwith comply w' those provisions.
-Datlo Applicant:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION ERAGE IS UNLAWFUL, AND SHALL
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL F NES UP TO ONE HUNDRED THOUSAND
DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
APPLICANT ACKNOWLEDGEMENT
IMPORTANT Application is hereby made to the Director of Building and.Safety for a permit subject to the
conditions and restrictions set forth on this application. '
1. Each person upon whose behalf this application is made, each person at whose request and for
whose benefit work is performed under or pursuant to any permit issued as a result of this application,
the owner, and the applicant, each agrees to, and shall defend, indemnify and hold harmless the City
of La Quinta, its officers, agents and employees for any act or omission related to the work being
performed under or following issuance of this permit.
-2. Any permit issued as a result of this application becomes null and void if work is not commenced.
within 180 days from date of issuance of such permit, or cessation of work for 180 days will subject
permit to cancellation. .
I certify that I have read this application and state that the above information is correct. I agree to comply with all
city and county ordinances and state laws relating to building construction, and hereby authorize representatives
of this count to enter upon the above-mentioned property for in paction purposes. '
DattT�'JJ Signature (Applicant or Agent):
I �
'Application Number ..: 06-00002878
Permit MECHANICAL
Additional desc .
Permit Fee- 24.00
Plan -Check
Fee
6.00
' Issue Date.`
Valuation
:
0
Expiration Date.. 1/29/07
Qty Unit Charge Per
Extension
BASE
FEE
15.00 .
1.00 9.0000 EA MECH.APPL
REP/ALT/ADD
9.100
-------------------------------------
Special,Notes and Comments
---------------------------------------
REPLACE A/C CONDENSING'SECTION
Fee summary Charged
Paid Credited
Due
Permit Fee Total 24.00
.00
.00
24.00
Plan Check Total 6.00
.00
.00
6.00
y Grand Total 30:00
.00
.00
30.00
LQPERMIT - _
Bin #
I-
City of La -Q nta
Building 8t Safety Division
P.O: Box 1504, 78-495 Calle Tampico
U Quinta, CA 92253 - (760) 777-7012
Building Permit. Application and Tracking Sheet
Permit #
Project Address: X7,9 4:20 V/ ZZh 5e VjZZ-,+
Owner's Name: Z aC erO
A. P. Number:
Address: V1L1 Z -'_5e ✓i ZZA
Legal Description:
City, ST, Zip: L,, Qu j,v /,4
Contractor: `'c7 ✓o-�i la % Ler; �i'IC ah� AIC
Telephone: 1,76L1):—,578-5048'
Address: e 3— 2 3/ /-/(,try. l I I
Project Description:
City, ST, zip: rr7d1a , CA- 9a;2.9/
ZaceAIC C�rdeNsi
Telephone: 760.— 347-. 3608
eC
State Lie. # :
City Lic. #:
Arch., Engr., Designer:
Address:
City, ST, Zip:
Telephone:
Construction Type: Occupancy:
State Lic. #:
Project type (circle one): New Add'n Alter Repair Demo
Name of Contact Person:
Sq. Ft.:
#Stories:
#Units:
Telephone # of Contact Person:
Estimated Value of Project:/ L906
APPLICANT: DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'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
Grading plan
god 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 correctionsfissue
Developer Impact Fee
Planning Approval
Called Contact Person
A.I.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees
Total Permit Fees
/VTT TTTTlV ♦ TT AT !\A1 LTT T ♦ 1T 11T TTL`ITr1T1T- ♦ T
n/C-r ICfy� Lulr `-iV .D- O(_ %,-
Project
Project Title
%�
g — 4.QVl L /,7 5-- V /L
�
L a LZ6 Date
Project Address G Building Permit #
'a✓a�-1aUgh Alec i -/c 7�P� •-347-3(OS
Documentation Author Telephone Plan Check /Date
S Field Check / Date
Compliance Method (Prescriptive) Climate Zone Enforcement Agency Use Only
✓ O Alternative Component Package Method: (check one) C D D (Alternative)
Package C and Package D choices require HERS rater field verification and/or diagnostic testing (see CF -'IR page 3)
For Package D Alternative see Appendix B Table 151-C Footnotes 7-14
GENERAL INFORMATION
Total Conditioned Floor Area (CFA) if 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) g
✓ ❑ 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 orientation 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, Frame
Roof, Floor, Type Cavity _ Continuous
Slab Edge, • (Wood Insulation Insulation_
Doors or Metal) R -Value R -Value
Assembly U -
factor (for
wood, metal
frame and mass
assemblies)
joint
Appendix
IV
Reference
Roof Radiant
Barrier Location/Comments
Installed (attic, garage,
Yes or No ical, etc.
1) See Joint Appendix 1 V in section 1 V.Z, 1 V.3 and 1 VA, wtuch is the basis for the 1 -1 -factor criterion. U -factors can not
exceed prescriptive value to show equivalence to R -values.
March 2005
CERTIFICATE OF COMPLIANCE: RESIDENTIAL (Page 2 of 4) CF -1R
�� chard L u �Qro ry g- a-
06
Project Title Date '
FENESTRATION PRODUCTS — U -FACTOR AND SHGC
[' FENESTRATION. MAXIMUM ALLOWED AREA WORKSHEET WS-4R—must be included for New Construction,
Additions and Alterations.
Fenestration
Duct or Piping . Thermostat Configuration
R -Value Type (split or package)
Thermostat Configuration
(split or Mkage)
#/Type/Pos.
Exterior
(Front, Left, Orien-
Shading/Overhangs6•'
Rear, Right, tation,
Area
U -factor
SHGC
✓ box if.WS-3R is
S light) N, S, E, W'
(fe) U -factor'
Source' SHGC°
Sources
included
13
-❑
❑
O•
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 Residential Manual
4 2) Enter values in this column are either NERC Rated value or from Standards default Table 116A.
3) Indicate source either from NFRC or Table 116A,
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
• i
Heating Equipment Minimum Distribution
Type and Capacity Efficiency Type and Location
furnace heat pump; boiler etc. AFUE or HSPF ducts attic etc.
Duct or Piping . Thermostat Configuration
R -Value Type (split or package)
Thermostat Configuration
(split or Mkage)
Cooling Equipment
Type and Capacity'
A/C heat pump,eva . cooling)
Minimum
Efficiency Duct Location, Duct
SEER or EER attic etc. R -Value
Thermostat Configuration
(split or Mkage)
CERTIFICATE OF COMPLIANCE: RESIDENTIAL (Page 3 of 4) C&M
�iG�aroC /ztc�ro-�-.�
Project Title Date
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
'OR
❑ Alternative to Sealed Ducts and Refrigerant Charge /I'XVs (See Package D Alternative Package Features for
Project 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
s aces shall meet the MqUireffithts of Section 150 in and duct insulation r - i ireinents of Package D.
WATER HEATING SYSTEMS
Distribution
Type
Number
in System
Check box if system meets criteria of a "Standard" system. Standard system is one gas-fired water heater per
❑
Sealed Ducts all climate zones). Installer testing and certification and HERS rater field verification required.)
Standby
Loss %
❑
TXVs, readily. accessible (climate zones 2 and 8-15 only)
-testingand
Check box when using Preapproved Alternative Water Heating table, Table 5-4 in Chapter 5 in the Residential
(Installercertification and HERS Rater field verification required.)
❑
Refrigerant Charge (climate zones 2 and 8-15 only) (Installer testing and certification and HERS Rater field
Alternative Water Heating table. In this case, the Performance Method must be used and must be included in the
verification required.)
'OR
❑ Alternative to Sealed Ducts and Refrigerant Charge /I'XVs (See Package D Alternative Package Features for
Project 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
s aces shall meet the MqUireffithts of Section 150 in and duct insulation r - i ireinents of Package D.
WATER HEATING SYSTEMS
Systems serving single dwe ling units
Water Heater
Type/Fuel Type
Distribution
Type
Number
in System
Check box if system meets criteria of a "Standard" system. Standard system is one gas-fired water heater per
❑
dwelling unit. If the water heater is a storage type, 50 gallons is the maximum capacity and recirculation system is
Standby
Loss %
not allowed.
O
Check box when using Preapproved Alternative Water Heating table, Table 5-4 in Chapter 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.
❑
Check box to verify that a time control is required for a recirculating system pump for a system serving multiple
units
Systems serving single dwe ling units
Water Heater
Type/Fuel Type
Distribution
Type
Number
in System
Rated
Input
(kW or
BUAr)
Tank
Capacity
(gaeons
Energy
Factor or
Thermal-
Efficiene
Standby
Loss %
Tank
External
Insulation
R -Value
t
System serving multiple d elling units
Water Heater
Type
Distribution
Type
Number
in System
Rated
Input
(kW or,
BtW11r)
Tank
Capacity
OzMIons
Energy
Factor or
Thermal
Efficiency
Standby
Loss %
Tank
External
Insulation
R -Value
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 instantaneous gas water
heaters, list Rated Input and Thermal Efficiencies.-
Pipe
fficiencies.Pipe Insulation (kitchen lines >_ 3/4 inches). All hot water pipes from the heating source to 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 March 2005
CERTIFICATE OF COMPLIANCE: RESIDENTIAL (Page 4 of 4) CF -1R
Ri �drord ' L &-f C-er®
Project Title Date
SPECIAL FEATURES NOT REQUIRING HERS VERIFICATION (add extra sheets if necessary)
Indicate which special features are part of this project. The list below only represents special features relevant to the
nrescrintive method. _
✓
Feature IRequired
Forms if a licable
Description
❑
Metal FramedWalls
CF -1R
Refrigerant Charge
❑
Radiant Barriers
CF -1R
CF -6R part 6 of 12
❑
Exterior Shades
WS4R
❑
Cool Roof
N/A; Attach CRRC Label to
Forms.
❑
Dedicated Hydronic Heating
Performance Calculation
System
Required; Attach Run to Forms.
❑
Combined Hydronic System
Performance Calculation
Required; Attach Run to Forms.`
E3
Gas Cooling
Performance Calculation
Required.
❑
Buried Ducts
N/A;•Indicate on building plans.
•
Kitchen Pipe Insulation
See Section 5.6.2 Distribution
Systems in Residential Manual.
❑
Multiple Water Heaters Per
See Table 5-13 or use
Performance Calculation and
Dwelling Unit
attach Run to Forms.
❑
Central Water Heating System
Performance Calculation and
Serving Multiple Dwellings
attach Run to Forms.
❑
Non-NAECAJLarge Water
CF -1R
r
Heater
See Table 5-13 or use
❑
Indirect Water Heater
Performance Calculation and
t
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
❑
Wood Stove Boiler
Performance Calculation and
attach Run to Forms
.t
SPECIAL FEATURES REQUIIt NG HERS RATER VERIFICATION
Ladd extra sheets if necessary) Indicate to the HERS Rater which credits are part of this project and need
verification.' "
✓
Feature
Reaired Forms if a licable Descri 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
INSTALLATION CERTIFICATE (Page 3 of 12). CF -6R
r78- 420 V, ZZA- Se vel /t LA Quin/
Site Address Permit Number
An installation certificate is required to be posted at the building site or made available for all appropriate inspections. (The '
information provided on this form is required) 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. heatpump).Number
CEC Certified Mfr.
Name and Model
# of
Identical
Systems
Efficiency
Wilt, etc.)
ZCF-IRvalue
Duct
Location
attic etc.
Duct or
Piping
R -value
Heating
Load
tu/hr
Heating
Capacity
BWft
C"onci S�z�o�
p 3aiVRp4
3
fjfy`ic
4��
481c
Cooling Equipment
Equip Type
(pkg. heat um
CEC Certified Mfr.
Name and Model
Number.
k of
Identical
Systems(>_CF-]Rvalue)
Efficiency
t
(SEER or EER)
Duct
Location
attic etc.
Duct
R -value
Cooling
Load
ft/hr(Btu/hr)
Cooling
Capacity
C"onci S�z�o�
p 3aiVRp4
3
fjfy`ic
4��
481c
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, 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.
. , g=a- o� Cara�auy%�l ric aro Air C'ond;41bmil-
Signature, Date Installing Subcontractor (Co. Name)
OR General Contractor (Co. Name) OR Owner
COPY TO: Buildirig Department
HERS Rater (if applicable)
Building Owner at Occupancy
Residential Compliance Forms W March 2005
INSTALLATION CERTIFICATE (Page 4 of 12) CF -6R
7cl— 420 O 10" JSeV;Z a La Quti,14,4
Site Address
Permit Number
INSTALLER COMPLIANCE STATEMENT FOR DUCT LEAKAGE
Copies to: Builder, HERS Rater, Building Owner at Occupancy and Building Department
INSTALLER COMPLIANCE STATEMENT
The building was: ✓ 13Tested 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 properly sealed:
❑ Inspect all joints to ensure that no cloth backed rubber adhesive duct tape is used
✓ ❑ DUCT LEAKAGE REDUCTION
Procedures for Meld verification and dtaznostic testinz of air distribution systems are available in RACM, Annendix RC4.3
NEW CONSTRUCTION:
Duct Pressurization Test Results (CFM @ 25 Pa)
Measured
Values
1
Enter Tested Leakage Flow in CFM:
Fan Flow: Calculated (Nominal: ✓xcooling�✓ ❑ Heating) or ✓ ❑ Measured
2
If Fan Flow is Calculated as 400 cfin/ton x number of tons or as 21.7 cfin/(kBtu/hr) x Heating
' ( 0 O
Ca acity in Thousands of Btu/hr, enter total calculated or measured fan flow in CFM here:
✓ ✓
3
Pass if Leakage Percentage< 6% for Final or < 4% at Rough -in:
ti Pass E3- Fall
100 x [_(Line # 1 / —(Line # 2
ALTERATIONS:
Duct System and/or HVAC Equipment Change -Out
Enter Tested Leakage Flow in CFM from Pre -Test of Existing Duct System Prior to Duct
4
System Alteration and/or Equipment Change -Out.
d
Enter Tested Leakage Flow in CFM from Final Test of New Duct System or Altered Duct
5
System for Duct System Alteration and/or Equipment Chane-Out.
a -
Enter Reduction in Leakage for Altered Duct System
6_(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 S 6% for Final or S 4% at Rough -in
Pass ❑ Fail
8
100 x ine # 5 /: Line # 2)11
raj
'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 <_ 15% [100 x [ 0a2 (Line # 5) / J,.(e00 (Line # 2)]]
Pass ❑ Fail
10
Pass if Leakage to Outside Percentage:5 10% [100 x [ (Line # 7) / (Line # 2)]]
❑ Pass ❑ Fail
Pass if Leakage Reduction Percentage >- [
60% [100 x (Line # 6) / (Line # 4)]]
13 Pass ❑ Fail
11
and Verification b Smoke Test and Visual Ins Inspection
12
Pass if Sealing of all Accessible Leaks and Verification by Smoke Test and Visual Inspection
❑ Pass ❑ Fail
Pass if One of Lines # 9 through # 12 pass
XPass ❑ Fail
I
✓ J4 I, the undersigned, verify that the above diagnostic test results
were performed in conformance with 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 }'n
Section 150 (m) of the 2005 Building Energy Efficiency Standards. C c9 Va 11'a /'1,6 JJ 'LC?Le o 4 /!C anGl Air Co-x;lt'
Ta e „(f Date Installing Subcontractor (Co. Name) OR
aL14 L e .-2 — General Contractor (Co. Name)
Residential Compliance Forms March 2005
INSTALLATION CERTIFICATE 1 (Page 5 of 12) CF -6R
Site Address
✓ 7s - Sao
,444 Permit Number ViL����v'`a[
THERMOSTATIC
EXPANSION VALVE (TXV)
Procedures for field ver cation of thermostatic expansion valves are available in RACM, Appendix Rl.
Access is provided for inspection. The procedure shall
consist of visual verification that the TXV is installed on
✓ Yes O No the system and installation of the specific equipment HO shall be verified.
Yes is a pass I Pass I Fail
✓ ❑ REFRIGERANT CHARGE MEASUREMENT
Verification for Required Refrigerant Charge and Adequate Airflow for Split System Space Cooling Systems without
ThPfffmnctatii;. FVhhhi inn ViihiPc
Outdoor Unit Serial #
Location
Outdoor Unit Make
Outdoor Unit Model
Cooling Capacity BWft
Date of Verification
Date of Refrigerant Gauge Calibration (must be checked monthly)
Date of Thermocouple Calibration (must be checked monthly)
R
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 Temaeratures
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)
°F
Condenser (entering) air dry-bulb temperature (Tcondenser, db)
OF
Superheat Charee Method Calculations for Refrieerant Charee
Actual Superheat = Tsuction, db — Tevaporator, sat
°F
Target Superheat (from Table RD -2) -
°F
Actual Superheat — Target Superheat (System passes if between -5 and +5°F)
°F
Temperature Split Method Calculations for Adequate Airflow
.Sn1it Mpthnd Calculatinn is not necessary ifAdeauate Airflow credit is taken
Actual Temperature' Split = T return, db Tsupply, db
OF
Target Temperature Split (from Table R133)
OF
Actual Temperature Split Target Temperature Split (System passes if between -
31F and +3°F or, upon remeasurement, if between -3°F and -100°F
OF
Residential Compliance Forms
March 2005
INSTALLATION CERTIFICATE (Page 6 of 12) CF -6R
70 - 420 VIZ I+- S9epll&A L A aalif it
Site Address Permit Number
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 13 No 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 OF or above, installer
shall use the Standard Charge Measure Procedure:
Procedures for Determining Refrigerant Charge using the Alternate Method are available in RACM, Appendix RD3.
Wei -In Charging Method for Refrigerant Charge
Actual liquid line length: ft
Manufacturer's Standard liquid line length: fi
Difference (Actual — Standard): ' ft
Manufacturer's correction (ounces per foot) x difference in length = ounces
(+ = add) (- = remove)
Measured Airflow Method for Adequate Airflow Verification available in RACM,•A endix RD2.6
Calculated Airflow: Cooling Capacity (Btu/hr) X 0.033 (cfmBtu-hr) = CFM
Measured Airflow is CFM (Measured airflow must be greater than the calculated airflow).
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 17 No System Passes
_QaL*,a4_ 51 1-:1ec Iricam'd 41r Cord, -fjo-oliyl
Signature, Date V Installing Subco actor (Co. Name) OR
General Contractor (Co. Name) OR Owner
COPY TO: Building Department
HERS Rater (if applicable)
Building Owner at Occupancy
Residential Compliance Forms March 2005