HomeMy WebLinkAboutPR17-11089CITY OF DIAMOND BAR J
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21810 Copley Drive, Diamond Bar, CA 91765 PRESS
(909) 839-7020 Fax: (909) 861-3117 Building Inspection Hotline (909) 839-7027 FIRMLY
BUILDING PERMIT APPLICATION www.cityofdiamondbar.com building@diamondbarea.gov
JOB SITE ADDRESSC Y �_e
APN LO TRACT
OWNER S
ADDR��jjSS '�
CITYiJ'GLa/k�fyr Ci1�ZIP %JTEL. �i.� ]�
APPLICANT. - � r �� TEL. 1,_ -
CONTRACTOR Se -C `/Y C -°P C;,
! � '
ADORE S _- L, S i
CITY ' ZIP T11-1 UTEL. I -
ARCH/ENG/
DESIGNER
ADDRESS
CITY ZIP TEL,
OWNER -BUILDER DECLARATION
I hereby affirm under papally of perjury that I am exempt from the Contractor's State License Law for the reason(s)
indicated below by the checkmark{sj, I have placed next to the applicable item(s1 [Section 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 appricantfor the permitto file a signed statement that he or she
is licensed pursuant to the provisions of the Contractor's Stale License Law (Chapter 91 Commencing with Section
7000 of Division 3 of the Business and Professions Cade] ar that he or she is examptfrom licensure and the basis for
the alleged exemption. Anyviolation of Sectlon 7031.5 by any applicant for a permit sublectsthe appllcantto a civil penalty
Df not more than five hundred dollars (5500),
O I, as owner of the property, or my employees with wages as their sole compensation, will do { ] of of or (-) portions
of the work, and the structure Is not intended or offered for sale (Section 7044, Business and Professions Code: The
Contractors' State License Law does not apply to an owner of prapedy who, through employees' or personal effort, builds
or improves the property, provided that the improvements are not intended or offered for sale. If however, the building or
Improvement is sold within one year of completion, the Owner -Builder will have the burden of proving that It was not built
or Improved for the purpose of sale.)
U I, as owner of the property, am exclusively contracting with licensed Contractors to construct the pmlect (Section
7044, Business and Professions Coda The Contractors' State License Law does not apply to m owner of property who
tuiids or Improves thereon, and who contracts forthe projects with a licensed Contractor pursuant to the Contractors' Slate
License Law),
U I am exemptfrom ilcensure under the Contractor's State License law for the following reasoni
Date: Sign,
By my signature below I acknowledge that, except for my personal residence in which I must have resided for at least one
year priorto completion otthe improvements covered by this permit,) cannot legally sell a structure that I have built as an
owner -builder if it has not been constructed in its entirety by licensed contractors, I understand Stat a copy of the
applicable law, Section 7044 of the Business and Professions Code is available upon request when this application Is
submitted or at the following Web site: http/www.leginfo.ca,govlcalaw,html.
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 {commencing with Section 7000}
of Division 3 of the Business and Professions Code, and my incense is in full force and effect.
i
LICENSE CLASS: LIC, NO.:
EXP, DATE:�' / CONTRACTOR: �E✓r�--��-�� C'
WORKER'S COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE Of THE FOLLOWING DECLARATIONS!
i I have and will maintain a Certitcate of Consent to Self -Insure for Worker's Compensation, as provided by
�ecfan 3700 of the Labor Code, for the performance ofthe work for which this permit Is Issued.
r ✓ I have and will maintain Worker's Compensation Insurance, as required by Section 3700 ofthe Labor Code, for
the perfarmance of the work for which this permit is issued. My Worker's Compensation Insurance Carrier and
Policy Number
i
CARRIER 1 !
CC
POLICY NUMBER
{THIS SECTION NEED NOT BE COMPLETED IF TNF PERMIT IS FOR ONE HiJNDRED DOLLARS $100 OR LESS).
I ceritthat in the performance of the worktor which this permit Is issued, I shall Rol employ any person in any manner so as to
i become subject to the Workers Compensatior Laws of California. And agree that I I should tecome subject to the Worker's
Compensatlon provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions.
DATE: APPLICANT:
WARNING: Failure to secure Worker's Compensation coverage Is unlawful and shall subject an employer to criminal
7 penalties and civil fires up to one hundred thousand dollars ($100,000, in addition to the cost of the compensation,
5 damages as provided for in section 3708 of the labor code, Interest, and attarney's fees.
- CONSTRUCTION LENDING AGENCY
3 I hereby affirm under penalty of perjury that there Is a Construction Lending Agency for the performance of rho work for
which this permit is issued (Sec. 3097, Civ. C.}.
LENDER'S NAME:
LENDER'S ADDRESS:
J
- I certify chat I have read this apppcatlon and state that the above Information is correct. I agree to comply with all city and
county ordln cos and state laws relating to building construction, and hereby authorize representatives of this county to
enter upa a hove -mentioned property for inspection purposes.
PERMITTEE NAME
a
SIGI PERNtffEE DATE
APPLICATION
ISSUE DATE:
TYPE CONST.
OCC GROUP:
Area:
TOTAL FEES
COMMENTS:
PlC: PAID BY: VALIDATION: g
RECEIPT# 3512 s PAID BY' -!p� Pp S 7&- VALIDATION: 1/ `--'
W RITE Department Copy, YELLC W —Finance Copy, PINK —Assessor Copy
QUANTITY DESCRIPTION
FEE
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CONSTRUCTION:
PLAN REVIEW:
ELECTRIC:
PLUMBING:
MECHANICAL:
INSPECTION FEE:
ISSUANCE:
SMTP:
ENERGY P/C:
ENERGY PERMIT:
RETENTION FEE:
PRE -ALT FEE:
BASF:
PLOT PLAN:
ZONING CLEARANCE:
TOTAL FEES
COMMENTS:
PlC: PAID BY: VALIDATION: g
RECEIPT# 3512 s PAID BY' -!p� Pp S 7&- VALIDATION: 1/ `--'
W RITE Department Copy, YELLC W —Finance Copy, PINK —Assessor Copy
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CERTIFICATE OF VERIFICATION
CF3R-MCH-25-H
Refrigerant Charge Verification
(Page 1 of 4)
Project Name:
JILL FOSTER
Enforcement Agency: Diamond
Bar (City of)
Permit Number: PR17-11089
Dwelling Address:
609 RITTER ST
City: DIAMOND BAR
Zip Code: 91765
A. System Information
HERS Rater to field -verify all system information, discrepancies to be noted by overwriting entry.
01
System Identification or Name
SYSTEM 1
02
System location or Area Served
WHOLEHOUSE
03
Condenser (or package unit) make or brand
LENNOX
04
Condenser (or package unit) model number
XC21--036-230-10
05
Nominal Cooling Capacity (tons) of Condenser
3
06
Condenser (or package unit) serial number
5817B11932
07
Refrigerant Type T
R -410A
OS
Other Refrigerant Type (if applicable)
This Field or section is not applicable
Liquid Line Filter Drier Installed According to Manufacturers"
Yes
09
Specifications (if applicable)
10
System Installation Type
Alteration
Fault Indicator Display (FID) Status (Note: Even systems with
This system `does not have a FID device installed
11
a FID must have refrigerant charge verified.by,_€nstallerJ
Is the system of a type that the minimum airflow can be
Yes, this is a ducted system and one of the system airflow
12
verified using an approved measurement procedure (RA3.3
rate measurement procedures in RA3.3 or RA3.3.3 can be
or RA3.3.3)?
used to verify system airflow rate requirements.
Is the system of a type that approved refrigerant charge
Yes, one of the Refrigerant charge verification procedures
verification procedures can be used to verify compliance
from RA3.2.2 or RAI is applicable to this system and can be
13
with the refrigerant charge verification requirements when
used to verify compliance
temperatures are >= 55°F (RA3.2.2, or RA1)?
14
Date of Refrigerant Charge Verification for this system
2017-08-30
Refrigerant charge verification method used.
Subcooling (outdoor temperature must be equal to or
15
greater than 55 degF)
Person who performed the Refrigerant Charge Verification
HERS rater
16
reported on this Certificate of Installation
17
HERS Verification Compliance Requirement Status
System does not qualify for group sampling
18
Refrigerant charge verification method used by HERS Rater.
Subcooling
Registration Number: Registration Date/Time: 2017-09-01 23:40:22 HERS Provider: CHEERS
417-A020106979A-003-000-M 25000A -M 25A
CA Building Energy Efficiency Standards Report Version: 2016.1.006 Report Generated: 2017-09-01 23:40:22
2016 Residential Compliance Schema Version: rev 10/16
CERTIFICATE OF VERIFICATION CF3R-MCH-25-H
Refrigerant Charge Verification (Page 2 of 4)
MCH -25b - Refrigerant Charge Verification - Subcooling Method
B. Metering Device Verification
HERS Rater is required to visually field verify all information from CF2R. Subcooling Method can only be used on
systems that have a variable metering device.
1 01 1 Refrigerant metering device j Thermostatic Expansion Valve (TXV)
02 I Subcooling Method applicability status I Subcooling Method is applicable to this system.
C. Instrument Calibration
HERS Raters are required to calibrate their diagnostic tools. Procedures for instrument calibration are given in
Reference Residential Appendix RA3.2.2 and RA3.2.2.2
01
Date of Digital Refrigerant Gauge Calibration
2017-08-01
02
Date of Digital Thermocouple Calibration
2017-08-01
03
Digital Refrigerant Gauge Calibration Status
Calibration is current
04
Digital Thermocouple Calibration Status
Calibration is current
D. Measurement Access Hole (MAH) Verification
HERS Raters are required to visually field,verify MAH., Procedures for,;instal.li.ng MAH are specified in Reference
Residential Appendix RA3.2.2.3
01 Method Used to Demonstrate Compliance with the MAH installed and labeled consistent with Figure 3.2-1
Measurement Access Hole (MAN) Requirement
E. Minimum System Airflow Rate Verification
Procedures for verifying minimum system airflow are specified in Reference Residential Appendix RA3.3.3.
01
Minimum Required System Airflow Rate (cfm)
900
System complies using the alternative remedial actions
02
System Airflow Rate Verification Status
specified in RA3.3.3.1.5. This System does not qualify for
group sampling
F. Data Collection and Calculations
HERS Rater must independently collect all data in this section. Procedures for determining Refrigerant Charge using
the Standard Charge Verification Procedure are given in Reference Residential Appendix RA3.2.2 and RA3.2.2.2
01 I Lowest Return Air Dry Bulb Temperature that Occurred 173
During the Refrigerant Charge Verification Procedure (°F)
Registration Number: Registration Date/Time: 2017-09-01 23:40:22 HERS Provider: CHEERS
417-A020106979A-003--000-M 25000A -M 25A
CA Building Energy Efficiency Standards Report Version: 2016,1.006 Report Generated: 2017-09-01 23:40:22
2016 Residential Compliance Schema Version: rev 10/1.6
CERTIFICATE OF VERIFICATION CF3R-MCH-25-H
Refrigerant Charge Verification (Page 3 of 4)
F. Data Collection and Calculations
HERS Rater must independently collect all data in this section. Procedures for determining Refrigerant. Charge using
the Standard Charge Verification Procedure are given in Reference Residential Appendix RA3.2.2 and RA3.2.2.2
02
Measured Condenser Air Entering Dry -Bulb Temperature
92
02
(Tcondenser,db)
133
03
Outdoor Temperature Qualification Status
Outdoor temperature is within range for using Subcooling
03
Digital Gauge or P -T Table using Line G02 (°F)
refrigerant charge verification method
04
Measured Liquid Line Temperature (Tuquid) (°F)
98
05
Measured Liquid Line Pressure (P:iquid) (psig)
346
Condenser Saturation Temperature (Tcordenser, sat) from
106
46
Digital Gauge or P -T Table using Line F05 (°F)
Yes, documentation to be provided upon request
07
Measured Subcooling (Line F06 - Lilne F04 ('F)
8
08
Target Subcooling from Manufacturer (°F)
5
09
Compliance Statement:
System complies with Subcooling Method -Must also pass
metering device verification, next section
G. Metering Device Verification
HERS Rater must independently collect all data in this section. Procedures for the verification of proper metering
device operation are specified in RA3.2...2.6.2..
01
Measured Suction Line Temperature (Tsurr ars) (a F)
71
02
Measured Suction Line Pressure (Psuction) (psig}
133
Evaporator Saturation Temperature (Tevaporator, sat) from
46
03
Digital Gauge or P -T Table using Line G02 (°F)
04
Measured Superheat (Line G01- Line G03) (°F)
25
05
Measured Superheat (Line G04) is between 3°F and 267
Passes CEC requirement
(inclusive)
Measured Superheat (Line G04) is within Manufacturer's
Yes, documentation to be provided upon request
06
Specifications ( if known)
07
Compliance Statement:
Metering device verification passes
H. Determination of HERS Verification Compliance
All applicable sections of this document shall indicate compliance with the specified verification protocol requirements in order
for this Certificate of Verification as a whole to be determined to be in compliance.
01 I Complies: All specified verification protocol requirements on this document are met.
Registration Number: Registration Date/Time: 2017-09-01 23:40:22 HERS Provider: CHEERS
417-A0201069 79A -003-000-M 25000A- M 25A
CA Building Energy Efficiency Standards Report Version: 2016.1.006 Report Generated: 2017-09-01 23:40:22
2016 Residential Compliance Schema Version: rev 10/16
CERTIFICATE OF VERIFICATION CF3R-MCH-25-H
Refrigerant Charge Verification (Page 4 of 4)
Documentation Author's Declaration Statement
1. 1 certify that this Certificate of Verification documentation is accurate and complete.
Documentation Author Name:
Documentation Author Signature:
Garrett Williams
Gar-rett-WaUa~
Company:
Date Signed:
I Permit E Raters
2017-09-01
Address:
CFA/ HERS Certification Identification (if applicable):
31225 La Baya Drive
RCN13056
City/State/Zip:
Phone:
Westlake Village CA 91362
818-735-7876
Responsible Person's Declaration statement
I certify the following under penalty of perjury, under the laws of the State of California:
1. The information provided on this Certificate of Verification is true and correct.
2. 1 am the certified HERS Rater who performed the verification identified and reported on this Certificate of Verification (responsible rater).
3. The installed features, materials, components, manufactured devices;or system performance diagnostic results that require HERS verification
identified on this Certificate &Verification comply with.the:applicable requirements in Reference Appendices RA2, RA3, and the requirements
specified on the Certificate of Compliance for the building approved'bythe-enforcement agency.
4. The information reported on applicable sections of the Certificate(S)of Installation (CF2R) signed and submitted by the persons) responsible for the
construction or installation conforms to the requirementsspec�fied,o.n the.Certificate(s) of Compliance (CF1R) approved bythe enforcement agency.
S. I will ensure that a registered copy of this Certificate of Verificatsari,shaikbe posted, or made available with the building permit(s) issued for the
building, and made available to the enforcement agency for ail applicable inspections. 1 understand that a registered copy of this Certificate of
Verification is required to be included with the documentation the biiider provides to the building owner at occupancy.
Builder Or Installer information As Shown On The Certificate Of Installation
Company Name (installing Subcontractor, General Contractor,or. Builder/Owner):
Service Champions
Responsible Builder or Installer Name:
CSLB License:
Austin Smith
799170
HERS Provider Data Registry Information
Sample Group Number (if applicable):
g Test Status in Sample Group (if applicable)
ENIA
HERS Rater Information
HERS Rater Company Name:
I Permit E Raters
Responsible Rater Name:
Responsible Rater Signature:
Garrett Williams
GarrettWaUaWW
Responsible Rater Certification Numberw/ this HERS Provider:
Date Signed:
RCN 13056
2017-09-01
Registration Number:
417-A020106979A-003-000-M25000A-M 25A
CA Building Energy Efficiency Standards
2016 Residential Compliance
Registration Date/Time: 2017-09-01 23:40:22 HERS Provider: CHEERS
Report Version: 2016.1.006 Report Generated: 2017-09-01 23:40:22
Schema Version: rev 10/16