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Home My WebLink AboutPR16-1209w CL z 0 0 W 0 0 0 0 0 z 0 0 z m cc 0 0 W LUz d rzo ti C) 0 Ea U LU z C) 0 U H 0 Z _N Y cc 0 H LU2 a K 0 w LLi m rn N rj 0 z z c7 U) i<1�1)ND BAR( CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES �� 21810 Copley Drive, Diamond Bar, CA 91765 WXD PRESS (909) 839-7020 Fax: (909) 861-3117 Building Inspection Hotline (909) 839-7027 FIRMLY BUILDING PERMIT APPLICATION www.cityofdiamondbar.com building@diamondbarca.gov JOB SITE ADDRESS T a r APN LOT TRACT OWNER ADDRESS ak"IT-) CITY �y 4�• ZIP q i U S- TEL. J Z I j j� 7 }� r4 APPLICANT d'4'/Yifi el TEL. CONTRACTOR iA)L % Y ADDRESS 16eia,rU CITY ZIPTEL. 44 1 6041 107h ARCH/ENG/ DESIGNER ADDRESS CITY ZIP TEL. OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury that I am exempt from the Contractor's State License Law for the reasons) indicated below by the checkmark(s), I have placed next to the applicable item(s) [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 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 from licensure 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). U I, as owner of the property, or my employees with wages as their sole compensation, will do U all of or U 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 property 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 project (Section 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 licensed Contractor pursuant to the Contractors' State License Law.). U I am exempt from licensure under the Contractor's State License law for the following reason(s): By my signature below I acknowledge that, except for my personal residence in which I must have resided for at least one year prior to completion of the 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 that 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.gov/calaw.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 license is in full force and effect. LICENSE CLASS: LIC. NO.: ( 041 DATE C CONTRACTOR: 21 1 WORKER'S COMPENSITION�RATION 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 Worker's Compensation, as provided by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My Worker's Compensation Insurance Carrier and Policy Numbera4 CARRIER IL ✓SID f I'� l �' C POLICY NUMBERt (THIS SECTION NEED NOT BE COMPLETED IF THE PERMIT IS FOR ONE HUNDRED DOLLARS ($100) OR LESS). I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Worker's Compensation Laws of California. And agree that if I should become subject to the Worker's Compensation provisi ns of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. w DATE: I IFAPPLICANT: WARNING: Failure to secure Worker's Compensatio overage is unlawful, and tall subject an employer to criminal penalties and civil fines up to one hundred thousand dollars ($100,000), in addition to the cost of the compensation, damages as provided for in section 3708 of the labor code, interest, and attorney's fees. 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: 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 county to enter upon the above-mentioned property for inspection purposes. PERMITTEE NAME (PRINT) SIGNATURE PERMITTEE DAT APPLICATION DATE: f DP/C# ISSUE DATE: c� / PERMIT#: ;C& TYPE CONST. 6k OCC GROUP: t; Fm pil�i gt W74 93 SO RM Scope of Work 91 F # DWEL. UNITS # STORIES # BEDROOMS DESCRIPTION SQ. FT. FACTOR PSF ADJ. AREA/VALUATION SFR/ADD/REM Garage/Carport LU Patio/Deck LU LL Pool/Spa ZRe -Roof I Commercial 7 m Valuation: Adj. Area: QUANTITY DESCRIPTION FEE U U w w ca J a FD L L 3 '- a U 'CAP qr x U CONSTRUCTION: PLAN REVIEW: ELECTRIC: PLUMBING: MECHANICAL: INSPECTION FEE: ISSUANCE: 3Si &Y SMTP: ENERGY P/C: ENERGY PERMIT: RETENTION FEE: PRE -ALT FEE: BASF: PLOT PLAN: ZONING CLEARANCE: TOTAL FEES COMMENTS: 9p1 117/ P/C: PAID BY: ) ✓� RECEIPT # -_ PAID BY: 31e ' VALIDATION: f VALIDATION WHITE —Department Copy, YELLOW —Finance Copy, PINK —Assessor Copy CITY OF DIAMOND BAR INSPECTION RECORD INSPECTION DATE INSPECTOR SETBACK/ LETTER FOOTINGS FORMS SLAB UG. PLUMBING UG. ELECTRICAL LIFER GROUND SEWER LATERAL MAIN WATER LINE SEWER CLEANOUT ROOF SHEATHING FLOOR SHEATHING SHEAR WALLS EXTERIOR SHEAR WALLS INTERIOR FRAMINGNENTING ROUGH MECHANICAL ROUGH ELECTRICAL W( ) C ( ) ROUGH PLUMBING INSULATION WALL INSULATION CEILING DRYWALL LATH (PRE) LATH EXTERIOR LATH INTERIOR GAS TEST SCRATCH COAT ELECTRIC METER RELEASE GAS METER RELEASE SPECIAL INSPECTION FINAL BUILDING FINAL MECHANICAL FINAL ELECTRICAL FINAL PLUMBING T.C. of OCCUPANCY CERT, of OCCUPANCY COMMENTS: t., INSPECTIONDATE INSPECTOR TRACT AND LEDGER SWITCH GEAR COMMERCIAL HOOD T -BAR INTERCEPTER HOT MOP/SHOWERPAN SEPTIC/CESSPOOL HERS REPORT RECEIVED % DEMOLITION ROOF DRAINS ROUGH CONDUIT POOUSPA ROUGH PLUMBING ROUGH ELECTRICAL ROUGH MECHANICAL GAS TEST PRE GUNITE POOL PRE DECK BONDING P -TRAP FENCE / GATE/ ALARM FINAL POOL WALLS: WALL FOOTING/STEEL WALL STEEL 1ST( ) 2N0( ) LIFT WALL BOND BEAM WALL DRAIN/ SEAL WALL FINAL R0. FRAMING PLANNING APPROVAL ROUGH FIRE APPROVAL FINAL FIRE DEPARTMENT FINAL PLANNING FINAL ENGINEERING/ PW FINAL COMMUNITY SERVICES FINAL HEALTH DEPT. FINAL INDUSTRIAL WASTE ALTERATIONS - HVAC C'= -C -CF I R -ALT -04-E (Revised 004'� CAUFORN'IA ENERGY COIMAASSION 1- - I i FICATE OF CON -4 CFIR-Al C T-0 -E -,,ERT! APLIANCE I AhLerations - HVAC CZ 2, and 8-15(formerly CF-1R-ALT-HVAC}(Page 1 of 1) t A d I r f2 s FAA, N D u: --t In 8g, P Je n, u m s t:e t: i Chi!:; i--.3ned Equipment Type Equipment Efficiency Req-uired R -value Floor Area (sq ft) I TherMoStat El Packaged System 0 Evaporator Coil r 0 R-6 (CZ Z 8-13) Ducting Serve:-,' by system AFUE COP ❑ I 11 Setback not abready DS plit System ❑0 Condensing Unit � ( —H 11 R-8'• /C7 11, 14, 15) ID u c t i n g 1 -qft ' 1 present, must 0 r-Aini Split D Compressor i SEER S F I : — - [I R-6 fahl CZ's) Plenums 1 1 11 Furnace 11 Lineset i t4 i ❑01 R-5 or 137-5) Linese b e ir, 5 t c-fle d) EER D TXV HERS VERIFICATION SUMMARY Installer determines work to be completed and matches to one of the options below. At permit application this form is allowed to be filled out by hand. For final inspection all forms are to be registered (no hand filled forms allowed) and a copy left on site. 0 1. HVACThangeout,/RePaIr Required Compliance Documents to be left on site for Final: All Equipment, CFIR-ALT-02-E Condenser Unit, Evaporator Coil, CF2R: tAr-:CH-01,MECH-20-HERS,MECH-(23or24)'-HERS,M.ECH-25-HERS2 Compressor, TXV, Uneset, CF3R: MECP,-20-HERS,MECH-(23or24)-LiERS2, MECH-25-HERS' Air Handler/Furnace' (Can include new ducting) I Installer Requirement: Duct leakage L15%, or < 10% to outside, or seal all accessible leaks), Air Flow >_� 300 CFM/ton, Refrigerant Charge. Exempted from duct leakage testing if: 13 1- Duct system registered with HERS provider as previously sealed, or 0 2. There is less than 40 linear feet of duct in unconditioned space, or 113. Existing duct systems are constructed, insulated or sealed with asbestos (list manufacture date of building 112. New HVAC System Required Compliance Documentsto be left on site for Final All new equipment and All New DUCtS3 CF1R-ALT-02-E including Mini Split CF2R: MECH-01,1V1ECH-20-HERS,PAECH-22-HERS,MECH-(23or24)-HERS',MECH-25-HERS 2 CF3R: MECH-20-HERS, MECH-22-HERS, MECH-(23 or 24) -HERS', IVIECH-25-HERS' Mini Splits require CFIR-ALT-02-E, CF2R-MECP-01, and (CF2R-CF3R) MECH-25-HERS Installer Requirement Duct leakage < 6%, Fan Efficacy (.58V4/CFM), Air Flow �: 350 CFM/Lon or alternative), Refrigerant Charge 113. All New Ducts with Replacement ~ Required Compliance Documents to be left on site for Final: All New DUCtS3 and one or more of the following CFIR-ALT-02-E nit, Evaporator Coil, replaced: Condenser Unit, CF2R: MECH-01,MECH-20-HERS,PAECH-(23or24)-HERS,tAECH-25-HERS Compressor, TK Lineset, Furnace' CF3R: MECH-20-HERS, MECH-(23 or 24) -HERS, MECH-25-HERS Installer Requirement: Duct leakage < 6%, Air Flow �: 350 CFM/ton (or alternative), Refrigerant Charge Exempted from duct leakage testing if: 0 1. Existing duct systems are constructed, insulated or sealed with asbestos El 4. New Ducting over 40 feet Required Compliance Documents to be left on site for Final New ducting but less than All New DUCtS3CF1R-AUi-ECF2R: NIECH -20-HERS, CF3R: MECH-20-HERS , Installer Required to: Duct leakage (< IS% or, < 10% to outside or, or sea[ all accessible leaks) 11 EXCEPTION: Existing duct systems constructed, insulated or sealed with asbestos. 'All new ducting R-9 required when more than 40 ft installed and R-6 when less than 40 ft installed. This includes in walls, between floors etc. 2 Heating only systems and Air Handler/Furnace changes do not require Air Flow MECH-(23 or 24), or Refrigerant Charge verification MECH-25 ' All New Ducts is when at least 75 percent of the duct system is new duct material, and up to 25 percent may consist of reused parts from the dwelling unit's existing duct system (e.g., registers, grilles, boots, air handier, coil, plenums, duct material) ' R-5 (1' thick insulation) for linesets V and less. R-7.5 (1.5" thick insulation) for linesets over I inch. Most mfg will require Suction line Diameter with insulation as the following 1.5 -2T -Vis", 2.5 -3T -2W, 3.5 to 4T -2X", 5T -4Y." Contractor (Documentation Author's /Responsible Designer'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 Compliance is true and correct 2. 1 am eligible under Division 3 of the California Business and Professions Code to accept responsibility for the information on this document. 3. That the energy features and performance specifications for the design identified on this Certificate of Compliance conform to the requirements of Title 24, Parts 1 and 6 of the California Code of Regulations (CCR). ; f 4. That the energy features and performance specifications, materials, components, and manufactured devices for the building design or system design identified on this Certificate of Compliance conform to the requirements of Title 24, Part 1 and Part 6 of the CCR. S. The building design features or system design features identified on this Certificate of Compliance are consistent with the information provided on other applicable compliance documents, worksheets, calculations, plans and specifications submitted to the enforcement i agency for approval with this building permit application. 1; Responsible Designer Name: Responsible Designer Signature: Date Signed: License: i Company: A.ddrps:-- City/State/Zip: City/State/7;p: Phone: For assistance or questions regarding the Energy Standards, contact the Energy Hotline at: I-800-77Z-3:1UU CERTIFICATE OF INSTALLATION CF2R-MCH-01-E Space Conditioning Systems, Ducts, and Fans (Page 1 of 7 ) Project Name: BHASKAR MANAM Enforcement Agency: City of Diamond Bar Permit Number: PR161209 Dwelling Address: 1522 SILVER RAIN DRIVE City: Diamond Bar Zip Code: 91765 A. General Information 01 Dwelling Unit Name BHASKAR MANAM 02 Climate Zone 9 07 Dwelling Unit Total Conditioned Floor 1436 04 Number of Space Conditioning 1 03 Area (W)Systems Installing aInstalling refrigerant new SC in this Dwelling Unit. Installing 05 Certificate of Compliance Type Prescriptive alterations (CF1R-ALT) 06 Method used to Calculate HVAC Loads NotApplicableEquipmentChangeout containing Calculated Dwelling Unit Sensible This field or section is not applicable 08 Calculated Dwelling Unit Heating Load This field or section is not applicable 07 Cooling Load (Btuh) 2 System (ft) system? (Bt uh) components? 09 Dwelling Unit Number of Bedrooms 3 MCH -01b Prescriptive Alterations - Space Conditioning B. Space Conditioning (SC) System Information',. r O1 02 03 04 05 06 07 08 09 30 SC System SC System CFA served Is the SC Installing aInstalling refrigerant new SC Installing more Installing Installing Identification or Location or Area by this SC a systemsystem ducted containing than 40 feet of entirely new entirely new SC Alteration Type Name Served 2 System (ft) system? component? components? ducts? duct system? system? Altered space System 1 Location 1 1436 Yes Yes Yes No No No conditioning system Registration Number: 216-A0186726A-M0100002B-0000 Registration Date/Time: 2016-06-29 13:01:24 HERS Provider: CalCERTS CA Building Energy Efficiency Standards - 2013 Residential Compliance Report Version: 2013 Rev 1.007 Report Generated: 2016-06-29 12:44:56 Schema Version: 2013.1.007 CERTIFICATE OF INSTALLATION CF2R-MCH-01-E Space Conditioning Systems, Ducts, and Fans (Page 7 of 7 ) Documentation Author's Declaration Statement 1. 1 certify that this Certificate of Installation documentation is accurate and complete. Documentation Author Name: Documentation Author Signature: Ibarra, Mina Company: Signature Date: i PERMIT E RATERS 2016-06-29 13:01:06 Address: CEA/ HERS Certification Identification (if applicable): 31225 La Baya Drive #213 City/State/Zip: Phone: West Lake 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 Installation is true and correct. 2. 1 under Division 3 of the Business and Professions Code in the applicable classification to accept responsibility for the system design, construction, or installation of features, materials, am eligible components, or manufactured devices for the scope of work identified on this Certificate of Installation, and attest to the declarations in this statement (responsible builder/installer), otherwise I am an authorized representative of the responsible builder/installer. installed features, materials, components or ma ufadured'dewcethe installatioidentified on this Certificate of Installation conformsao alllapplicable codes and regulations, and the n) 3. The constructed or ra t t _. =£ installation conforms to the requirements given on theiplans and specificationsrapproved'by the enforcementagency. e- this Certificate of 4. I reviewed a copy of the Certificate of Compliance approved by the'enforcement ag ncy that'identfies the pecific requirement;;for the scope of construction or�stallation identified on Installation, and I have ensured that the requiremen s that apply to the construction or installation have been met. or made available with the building permits) issued forahe building, and made:available to the enforcement agency for all 5. I will ensure that a registered copy of this Certificate oflnstallation shalbbe posted inspections. I understand that a registered copy of this Certificate oflnstallation is required to be included with the documentation the builder provides to the building owner at occupancy. applicable Responsible Builder/Installer Name: Responsible Builder/Installer Signature: Cochran, Rusty Company Name: (Installing Subcontractor or General Contractor or Builder/Owner) Position With Company (Title): W C HEATING & AIR CONDITIONING INC EMPLOYEE Address: CSLB License: 25976 MADISON AVE 779604 City/State/Zip: Phone: 1951-600-0700 Date Signed: 12016-06-29 MURRIETA CA 92562 13:01:24 Digitally signed by CaICERTS. This digital signature is provided in order to secure the content of this registered document, and in no way implies Registration Provider responsibility for the accuracy of the information. Registration Number: 216-A0186726A-M0100002B-0000 Registration Date/Time: 2016-06-29 13:01:24 HERS Provider: CaICERTS CA Building Energy Efficiency Standards - 2013 Residential Compliance Report Version: 2013 Rev 1.007 Report Generated: 2016-06-29 12:44:56 Schema Version: 2013.1.007 CERTIFICATE OF VERIFICATION CF3R-MCH-20-H Duct Leakage Diagnostic Test (Page 3 of 3 ) Documentation Author's Declaration Statement 1. 1 certify that this Certificate of Verification documentation is accurate and complete. Documentation Author Name: Documentation Author Signature: ��ffjjJJ //r i�(GsILGl�i/GicvtJLlL Mina Ibarra Company: Date Signed: i PERMIT E RATERS 2016-06-29 13:05:56 Address: CEA/ HERS Certification Identification (if applicable): 31225 La Baya Drive #213 City/State/Zip: Phone: West Lake 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 of Verification comply with the applicable requirements in Reference Appendices RA2, RA3, and the requirements specified on the Certificate of Compliance for the building approved by the enforcement agency. 4. The information reported on applicable sections of -the Certificates) of Installatipn}(CF2Rj stgne&and submittedlby the person(s) responsible for the construction or installation conforms to the.requirements'-specified-on the Certify te(s) of Compliance (CF1R) approved by&the enforcement=agency. 5. 1 will ensure that a registered cop` yy of this Certificate of yeri cation shall be posted or made€availab a with t3 building permit(s) issued for the for applicable inspections I-understan& hat a regisfikd copy of this.Certiiiicate of building, and made available to the.enforcement agency all Verification is required to be included with the documentation the builder provides to the building owner at occupancy. " Builder Or Installer Information As Shown On"The Certificatebf Installation Company Name (Installing Subcontractor, General Contractor, or Builder/Owner): W C HEATING & AIR CONDITIONING INC Responsible Builder or Installer Name: CSL13 License: Rusty Cochran 779604 HERS Provider Data Registry Information Sample Group Number (if applicable): Dwelling Test Status in Sample Group (if applicable) Tested HERS Rater Information HERS Rater Company Name: i PERMIT E RATERS Responsible Rater Name: Responsible Rater Signature: C�CG��/r/vr+Ct�rGW Richard Douthit Responsible Rater Certification Number w/ this HERS Provider: Date Signed: CC2006570 2016-06-29 13:06:06 Digitally signed by CaICERTS. This digital signature is provided in order to secure the content of this registered document, and in no way implies Registration Provider responsibility for the accuracy of the information. Registration Number: 216-A0186726A-M2000002A-M20A Registration Date/Time: 2016-06-29 13:06:06 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.007 Report Generated: 2016-06-29 13:03:53 2013 Residential Compliance Schema Version: 2013.1.007 CERTIFICATE OF VERIFICATION CF3R-MCH-23-H Space Conditioning System Airflow Rate (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: Mina Ibarra Company: Date Signed: i PERMIT E RATERS 2016-06-29 13:05:56 Address: CEA/ HERS Certification Identification (if applicable): 31225 La Baya Drive #213 City/State/Zip: Phone: West Lake 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 of Verification comply with the applicable requirements in Reference Appendices RA2, RA3, and the requirements specified on the Certificate of Compliance for the building approved by the enforcement agency. 4. The information reported on applicable sections &Ahe Certifica(s)hof,lnsfallation,(GF2R)Isignedtan' �submiitfediby the persons) responsible for the construction or installation conforms to the requirements'spenfied on the Cerdficate(s)'of Compliance (CFIR) approved by the enforcement agency. 5. 1 will ensure that a registered copy of this Certificate of.Verification shall be posted, or madeaavailabllee with the'building permit(g) _ issued for the building, and made available to the.enforcemantagent fo all applicable inspections. I understand that a registered copy off th..Cert ficate of Verification is required to be Included with the documentation the builder provides to the building owner at occupancy. Builder Or Installer Information As Shown On The Certificate&"6f Installation Company Name (Installing Subcontractor, General Contractor, or Builder/Owner): W C HEATING & AIR CONDITIONING INC Responsible Builder or Installer Name: CSLB License: Rusty Cochran 779604 HERS Provider Data Registry Information Sample Group Number (if applicable): Dwelling Test Status in Sample Group (if applicable) Tested HERS Rater Information HERS Rater Company Name: i PERMIT E RATERS Responsible Rater Name: Responsible Rater Signature: C�`��%�' ,` imr Richard Douthit Responsible Rater Certification Number w/ this HERS Provider: Date Signed: CC2006570 2016-06-29 13:06:06 Digitally signed by Ca10ERTS. This digital signature is provided in order to secure the content of this registered document, and in noway implies Registration Provider responsibility for the accuracy of the information. Registration Number: 216-A0186726A-M2300002A-M23A Registration Date/Time: 2016-06-29 13:06:06 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.007 Report Generated: 2016-06-29 13:04:18 2013 Residential Compliance Schema Version: 0.555SDD `-t 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: //�� Mina Ibarra -1001ro/kzlrw- Company: Date Signed: i PERMIT E RATERS 2016-06-29 13:05:56 Address: CEA/ HERS Certification Identification (if applicable): 31225 La Baya Drive #213 City/State/Zip: Phone: West Lake 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 of Verification comply with the applicable requirements in Reference Appendices RA2, RA3, and the requirements specified on the Certificate of Compliance for the building approved by the enforcement agency. 4. The information reported on applicable sections`&,'the Certificates) oflnstalla,ti,6n'(CF2R)�si'gned ancl'submlitoe&by the person(s) responsible for the construction or installation conforms to the requirements specifiedon the Certificate(s);of Compliance (CF.1R) approved by the,enforcement agency. » — 5. 1 will ensure that a registered copy, of this Certificate of Verification hall be posted, r madeiavailable with the=Building permits) issued for the A z i building, and made available;to the enforcement agency for all applicable inspections I understandthat a registeredacopy of this+Certificate,of _ , - _ - A 'w1 "'T y!'36, �' ?�9�i'ar�isi _ v e'wJ Verification is required to be`lncluded with the documentation the builder provides to the building owner at occupancy. Builder Or Installer Information As Shown OnThe'Certificate Of Installation ' Company Name (Installing Subcontractor, General Contractor, or Builder/Owner): W C HEATING & AIR CONDITIONING INC Responsible Builder or Installer Name: CSLB License: Rusty Cochran 779604 HERS Provider Data Registry Information Sample Group Number (if applicable): Dwelling Test Status in Sample Group (if applicable) Tested HERS Rater Information HERS Rater Company Name: i PERMIT E RATERS Responsible Rater Name: Responsible Rater Signature: / Jam),/. Richard Douthit _ e�Cl�i�(�l�%t/F9�LGIYG(/ Responsible Rater Certification Number w/ this HERS Provider: Date Signed: CC2006570 2016-06-29 13:06:06 Digitally signed by CaICERTS. This digital signature is provided in order to secure the content of this registered document, and in noway implies Registration Provider responsibility for the accuracy of the information. Registration Number: 216-A0186726A-M2500002A-M25A Registration Date/Time: 2016-06-29 13:06:06 HERS Provider: CaICERTS CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.007 Report Generated: 2016-06-29 13:05:06 2013 Residential Compliance Schema Version: 2013.1.007