HomeMy WebLinkAboutPR16-438DLU OND BA
CITY OF DIAMOND BAR F' HERS RATER
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21810 Copley Drive, Diamond Bar, CA 91765 ��RE� PRESS
(909) 839-7020 Fax: (909) 861-3117 Building Inspection Hotline (909) 8 FIRMLY
BUILDING PERMIT APPLICATION www.cityofdiamondbar.com building@diamondbarca.gov
JOB SITE ADDRESS
APN LOT TRACT
OWNER
ADDRESS
CITY ZIP TEL.
APPLICANT TEL qel 2
CONTRACTOR cowl "3
ADDRESS S
CITY rJ
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 reason(s)
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 sale 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,l 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.htmi.
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.
LICENS LASS: LIC. NO.:
CONTRACTOR:
WORKER'S COMAPENSin RATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOECLA TO
WING D
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.
� 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 Number are -
CARRIER w 18 I '
POLICY NUMBER c 5Z 2�
(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 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
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-meentiiooned property forinspectionpurposes.
ITTEE NAME (PRINT
NATUR • EE DATE
APPLICATION DATE: b 11(o P/C# ^—
ISSUE DATE: a` b ( �. PERMIT# : e-, ) 10 —
TYPE CONST. OCC GROUP:
Scope of Work
# DWEL. UNITS If STORIES # BEDROOMS
DESCRIPTION
SO. FT.
FACTOR PSF
ADJ. AREA/VALUATION
SFR/ADD/REM
Garage/Carport
wrn
Patio/Deck
w
W
Pool/Spa
ZRe
-Roof
Commercial
CO
CO
Valuation:
Adj. Area:
QUANTITY
DESCRIPTION
FEE
U
cr
L)
U
W
w
co
Z
J
a
ell
zd
x
U
W
CONSTRUCTION:
PLAN REVIEW:
ELECTRIC:
PLUMBING:
MECHANICAL: Z• (o %7r
INSPECTION FEE: �1
ISSUANCE: JS �A—
SMIP:
ENERGY P/C:
ENERGY PERMIT:
RETENTION FEE: a�
PRE-ALT FEE:
BASF:
PLOT PLAN:
ZONING CLEARANCE:
TOTAL FEES �S Z
COMMENTS:
P/C: ���� y.PAID BY: VALIDATION:
RECEIPT # �j��'RJ PAID BY: VALIDATION:1
WHITE — Department Copy, YELLOW — Finance Copy, PINK — Assessor Copy
. �ro �a
:i,b'
CUUM AMOND BAR
INSPECTION RECORD
INSPECTION
DATE
INSPECTOR
SETBACK/LETTER
FOOTINGS FORMS
SLAB
UG. PLUMBING
UG. ELECTRICAL
UFER 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:
INSPECTION
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 1 ST( ) 2ND( ) LIFT
WALL BOND BEAM
WALL DRAIN/ SEAL
WALL FINAL
RO. FRAMING PLANNING APPROVAL
ROUGH FIRE APPROVAL
FINAL FIRE DEPARTMENT
FINAL PLANNING
FINAL ENGINEERING/ PW
FINAL COMMUNITY SERVICES
FINAL HEALTH DEPT.
FINAL INDUSTRIAL WASTE
CERTIFICATE OF COMPLIANCE CF1R-ALT-02-E
Alterations to Space Conditioning Systems (formerly CF-1R-ALT-HVAC) (Page 3 of 3 )
Documentation Author's Declaration Statement
1. 1 certify that this Certificate of Compliance documentation is accurate and complete.
Documentation Author Name:
Kevin Burgeson
Documentation Author Signature:
//pp��11 (1 ..` f,• ✓r
Signature Date: ..,.._<
Company:
Burgeson's Heating and Air Conditioning, Inc.
2016-02-10
Address:
CEA/ HERS Certification Identification (if applicable):
620 Tennessee St
263871
City/State/Zip:
Phone:
Redlands CA 92374
909-793-3685
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 Compliance is true and correct.
2. 1 am eligible under Division 3 of the Business and Professions Code to accept responsibility for the building design or system design identified on this Certificate of Compliance (responsible designer).
3. 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 California Code of Regulations.
4. 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 agency for approval with this building permit application.
S. I will ensure+that a registered•copy of this Certificate of Compliance;shalhbe,mad"e available with the,building permits)+issued,for the building, and made available to the enforcement agency for all applicable
inspections nderstand that a registeered.copy oft Certificate of:Complian e is required to be:iricluudded with the do�cu entation the builder provides to the building owner at occupancy.
�scaa&
Responsible Designer Name: < r r
v
a ,6ns. ,r gnatu
Responsible Designer 5ignature:
Kevin Burgeson Y
r'� >/\�(���
Company: .> � �'
C, e, ,. b f r �:.
:Inc-. "" ""'
Date.Signed sue,;H
R i.
Burgeson's Heating;and?Air'Cohditloning F
2016`02 10
Address: y
620 Tennessee St U.S. Energy Ra
License: qq
�3�71iyssociatian
City/State/Zip:
Phone:
Redlands CA 92374
909-793-3685
Registration Number: 316-A1020161A-000000000-0000
'This digital signature. is provided in order to secure
the content of this registered document, and it no
way implies Registration,Provider responsibility for
the accuracy of the information.
Registration Date/Time: 2016-02-10 14:02:30
HERS Provider: USERA
CA Building Energy Efficiency Standards - 2013 Residential Compliance Report Version: 2013 Rev 1.007 Report Generated: 2016-02-10 14:04:34
Schema Version: 0.555SDD
,CERTIFICATE OF INSTALLATION CF2R-MCH-20-H
Duct Leakage Diagnostic Test (Page 3 of 3 )
Documentation Author's Declaration Statement
1. 1 certify that this Certificate of Installation documentation is accurate and complete.
Documentation Author Name:
Documentation Author Signature: I-\lk:�- v ' ' j J
Kevin Burgeson
Signature Date:
Company:
Burgeson's Heating and Air Conditioning, Inc.
2016-02-25 ==--- ---
Address:
CEA/ HERS Certification Identification (if applicable):
620 Tennessee St
263871
City/State/Zip:
1909-793-3685
Phone:
Redlands CA 92374
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 am eligible 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, 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.
3. The constructed or installed features, materials, components or manufactured devices (the installation) identified on this Certificate of Installation
conforms.to all applicable codes and regulations, and the installation conforms to the requirements given on the plans and specifications approved by
the enforcement agency.
4. 1 understand that a HERS rater will check the installation to verify compliance, and that if such checking identifies defects; l am required to take
corrective action at my expense. I understand that Energy Commission and HERS Provider representatives will also perform quality assurance checking
of installations, including those approved as part of a sample group but not checked by a HERS rater, and if those installations fail to meet the
requiremlentsof such quality assurance checking —,the required corrective action and additional checking/testing of other installations in that HERS
sample group `will be performed at my expense
5. 1 reviewed a,copy of the Certificate of Compliance app oved by the enforcement agency that identifies the specific requirements for the scope of
construction or installation identified on this Certificate of Installation, and I have ensured that the requirements that apply to the construction or
installation have been met. U.S Energy Raters Association
6. 1 will ensure that a registered copy of this Certificate of Installation shall be posted, r made available with the building permit(s) issued for the
building, and made available to the enforcement agency for all applicable inspections. I understand that a registered copy of this Certificate of
Installation is required to be included with the documentation the builder provides to the building owner at occupancy.
Responsible Builder/Installer Name:
Responsible Builder/Installer Signature:
Kevin Burgeson
Company Name: (Installing Subcontractor or General Contractor or
Position With Company (Title):
Builder/Owner)
Installer KEVIN BURGESON (Feb 25, 2016)
Burgeson's Heating and Air Conditioning, Inc.
Address:
CSLB License:
620 Tennessee St
263871
City/State/Zip:
Phone:
Date Signed:
Redlands CA 92374
909-793-3685
12016-02-25
Third Party Quality Control Program (TPQCP) Status:
Name of TPQCP (if applicable):
TM
This digital signature is provided in order to secure
— the content of this registered document, and in no
way implies Registration Provider responsibility for
U.S. Energy Raters Assoclatlon the accuracy of the information.'
Registration Number: 316-A1020161A-M2010504A-0000 Registration Date/Time: 2016-02-25 15:50:19 HERS Provider: USERA
CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.007 Report Generated: 2016-02-25 15:52:11
2013 Residential Compliance Schema Version: 2013.1.007
CERTIFICATE OF INSTALLATION CF2R-MCH-23-H
Space Conditioning System Airflow Rate (Page 3 of 3 )
Documentation Author's Declaration Statement
1.1 certify that this Certificate of Installation documentation is accurate and complete.
Documentation Author Name:
Documentation Author Signature: F\ n, v
Kevin Burgeson
Signature Date:I
Company:
Burgeson's Heating and Air Conditioning, Inc.
2016-02-25 —
Address:
CEA/ HERS Certification Identification (if applicable):
620 Tennessee St
263871
City/State/Zip:
1909-793-3685
Phone:
Redlands CA 92374
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 am eligible 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, 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.
3. The constructed or installed features, materials, components or manufactured devices (the installation) identified on this Certificate of Installation
conform.to,all applicable codes and regulations,. and the installation conforms to the requirements given on the plans and specifications approved by
___
the enforcement agency. ; /' -.7
4. 1 understand that a HERS rater will eheck'the installation to verify compliance, and that if such checking identifies defects; I am required to take
corrective action at my expense. I understand that. Energy Commission and'HERS Provider representatives will also perform quality assurance checking
of installations, including those approved as part of a sample group but not checked by a HERS rater, and if those installations fail to meet the
requiremlents,of such quality assurance checking`; the required corrective action and additional checking/testing of other installations in that HERS
sample group will b_e performed at my"expense i
5. I reviewed a copy of the Cert ficate`o`f Compliance.approved by the enforcement agency that identifies the specific requirements for the scope of
construction or installation identified on this Certificate of Installation, and I have ensured that the requirements that apply to the construction or
installation have been met. U.S. Energy Raters Association
6. 1 will ensure that a registered copy of this Certificate of Installation shall be posted, or made available with the building permit(s) issued for the
building, and made available to the enforcement agency for all applicable inspections. I understand that a registered copy of this Certificate of
Installation is required to be included with the documentation the builder provides to the building owner at occupancy.
Responsible Builder/Installer Name:
Responsible Builder/Installer Signature:
Kevin Burgeson
Company Name: (Installing Subcontractor or General Contractor or
Position With Company (Title):
Builder/Owner)
Installer KEVIN BURGESON (Feb 25, 20161
Burgeson's Heating and Air Conditioning, Inc.
Address:
CSLB License:
620 Tennessee St
263871
City/State/Zip:
Phone:
Date Signed:
Redlands CA 92374
909-793-3685
12016-02-25
Third Party Quality Control Program (TPQCP) Status:
Name of TPQCP (if applicable):
W
_, vs ! �/` "This digital signature is provided in order to secure
the content of this registered document, and in no
way implies Registration Provider responsibility for
U.S. Energy Raters Association the accuracy of the information.'
Registration Number: 316-A1020161A-M23008012A-0000 Registration Date/Time: 2016-02-25 T15:59:5 HERS Provider: USERA
CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.007 Report Generated: 2016-02-25 16:01:51
2013 Residential Compliance Schema Version: 0.555SDD
CERTIFICATE OF INSTALLATION CF2R-MCH-25-H
Refrigerant Charge Verification (Page 4 of 4 )
Documentation Author's Declaration Statement
1. 1 certify that this Certificate of Installation documentation is accurate and complete.
Documentation Author Name:
Documentation Author Signature: r\`izf- v I '' I J v
Kevin Burgeson��I'��//,�7�
Signature Date:
Company:
Burgeson's Heating and Air Conditioning, Inc.
2016-02-25 !n!= - -
Address:
CEA/ HERS Certification Identification (if applicable):
620 Tennessee St
263871
City/State/Zip:
Phone:
Redlands CA 92374
909-793-3685
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 am eligible 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, 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.
3. The constructed or installed features, materials, components or manufactured devices (the installation) identified on this Certificate of Installation
conform s.to all applicable codes and regulations,, and the installation conforms to the -requirements given on the plans and specifications approved by
the enforcement agency..
4. 1 understand that a HERS rater will check the installation to verify compliance, and that if such checking identifies defects; I am required to take
corrective action at my expense. I ulnderstand that Energy Commission and HERS Provider representatives will also perform quality assurance checking
of installations, including those approved as part of a'sample group but not checked by a HERS rater, and if those installations fail to meet the
requirements;of such quality assurance check ni g the required corrective action and additional checking/testing of other installations in that HERS
sample group will be performed at my expense.
5. 1 reviewed'a-copy of the Cert ficate of Compliance approved by the enforcement agency that identifies the specific requirements for the scope of
construction or installation identified on this Certificate of Installation, and I have ensured that the requirements that apply to the construction or
installation have been met. U.S. Energy Raters Association
6. 1 will ensure that a registered copy of this Certificate of Installation shall be posted, or made available with the building permit(s) issued for the
building, and made available to the enforcement agency for all applicable inspections. I understand that a registered copy of this Certificate of
Installation is required to be included with the documentation the builder provides to the building owner at occupancy.
Responsible Builder/Installer Name:
Responsible Builder/Installer Signature:
Kevin Burgeson
Company Name: (Installing Subcontractor or General Contractor or
Position With Company (Title):
Builder/Owner)
Installer KEVIN 6URGESON (Fab 25.201G)
Burgeson's Heating and Air Conditioning, Inc.
Address:
CSLB License:
620 Tennessee St
263871
City/State/Zip:
Phone:
Date Signed:
Redlands CA 92374
909-793-3685
12016-02-25
Third Party Quality Control Program (TPQCP) Status:
Name of TPQCP (if applicable):
Thi
J ; F �I This digital signature is provided in order to secure
i 4 the content of this registered document. and in no
I ��� way implies Registration Provider responsibility for
the accuracy of the information."
U.S. Energy Raters Association
Registration Number: 316-A1020161A-M25006846A-0000 Registration Date/Time: 2016-02-25 15:57:04 HERS Provider: USERA
CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.007 Report Generated: 2016-02-25 15:58:56
2013 Residential Compliance 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:
Armando Ulloa-Rocha
Date Signed:
Company:
Mandos Ducts
2016-02-25
Address:
CEA/ HERS Certification Identification (if applicable):
34975 Ave C #b
HERS
City/State/Zip:
Phone:
Yucaipa CA 92399
909-384-2773
Responsible Person's Declaration statement
1 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 infotmation reported on applicable sections of the, ertificate(s) of Installation (CF2R) signed and submitted by the person(s) responsible for the
construction or installation conforms to the -requirements specified on the Certificate(s) of Compliance (CF1R) approved by the enforcement agency.
S. I will ensure that a registered copy of this Certificate of Verification shall be posted, or made available with the building permit(s) issued for the
building, land made available to the enforcement agency for all applicable inspections. I understand that a registered copy of this Certificate of
Verification is required to be included with the documentation the builder provides to the building owner at occupancy.
Builder Or Installer Information At -Shown Orl Certificate Of Installation
Company Name (Installing Subcontractor, General Contractor ,orBuilderMr& Energy Raters Association
Burgeson's Heating and Air Conditioning, Inc.
Responsible Builder or Installer Name:
CSLB License:
Kevin Burgeson
263871
HERS Provider Data Registry Information
Sample Group Number (if applicable):
Dwelling Test Status in Sample Group (if applicable)
316-15112
Tested
HERS Rater Information
HERS Rater Company Name:
Mandos Ducts
Responsible Rater Name:
W // /1
Responsible Rater Signature: /) 4I /y2)0 l�/7ft
Armando Ulloa-Rocha
ARM
RMANDO ROCFIA (Feb 25, 2016)
Responsible Rater Certification Number w/ this HERS Provider:
Date Signed:
HERS
2016-02-25
TM
"This digital signature is provided in order to secure
3 L i the content of this registered document, and in no
----J �� way implies Registration Provider responsibility for
U.S. Energy Raters Assoclatlon the accuracy of the information."
Registration Number: 316-A1020161A-M20008444A-M20A Registration Date/Time: 2016-02-25 16:17:01 HERS Provider: USERA
CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.007 Report Generated: 2016-02-25 16:18:53
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:
Armando Ulloa-Rocha
L-
Date Signed:
Company:
Mandos Ducts
2016-02-25
Address:
CEA/ HERS Certification Identification (if applicable):
34975 Ave C #b
HERS
City/State/Zip:
Phone:
Yucaipa CA 92399
909-384-2773
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�Certificate(s) of Installation (CF2R) signed and submitted by the person(s) responsible for the
construction or installation conforms to the requirements specified on the Certificate(s) of Compliance (MR) approved by the enforcement agency.
5. I will ensure that a registered copy of this Certificate of Verification shall be.posted, or made available with the building permit(s) issued for the
building, and made available to the enforcement agency for all applicable inspections. I understand that a registered copy of this Certificate of
Verification isrequiredto be included with the documentation the builder provides to the building owner at occupancy.
1 x 1 i
Builder Or Installer Information At -Shown On,The Certificate Of Installation
Company Name (installing Subcontractor, General Contractor, orBuilder,�. Energy Raters Association
Burgeson's Heating and Air Conditioning, Inc.
Responsible Builder or Installer Name:
CSLB License:
Kevin Burgeson
263871
HERS Provider Data Registry Information
Sample Group Number (if applicable):
Dwelling Test Status in Sample Group (if applicable)
316-15112
Tested
HERS Rater Information
HERS Rater Company Name:
Mandos Ducts
Responsible Rater Name:
Responsible Rater Signature: /] nQ x��D pD/ /i /1
C116
Armando Ulloa-Rocha
f'`/� /� /�
ARMANDO ROCHA (Feb 25, 2016)
Responsible Rater Certification Number w/ this HERS Provider:
Date Signed:
HERS
2016-02-25
1 Al
"This digital signature is provided in order to secure
I L� the content of this registered document, and in no
way implies Registration Provider responsibility for
U.S. Energy Raters Association the accuracy of the information.'
Registration Number: 316-A1020161A-M23006114A-M23A Registration Date/Time: 2016-02-25 16:16:07 HERS Provider: USERA
CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.007 Report Generated: 2016-02-25 16:17:59
2013 Residential Compliance Schema Version: 0.555SDD
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:
Armando Ulloa-Rocha
Company:
Date Signed:
Mandos Ducts
2016-02-25
Address:
CEA/ HERS Certification Identification (if applicable):
34975 Ave C #b
HERS
City/State/Zip:
Phone:
Yucaipa CA 92399
909-384-2773
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 informatidn reported on applicable sections of the.Certificate(s) of Installation (CF2R) signed and submitted by the person(s) responsible for the
construction or installation conforms to the requirements specified on the Certificate(s) of Compliance (CF1R) approved by the enforcement agency.
5. 1 will ensure that a registered copy of this Certificate of Verification shall be, posted, or made available with the building permit(s) issued for the
building, land made available to the enforcement agency for all applicable inspections. I understand that a registered copy of this Certificate of
Verification is required to be included with the documentation the builder provides to the building owner at occupancy.
I l r n 1
Builder Or Installer Information As, -Shown O :The Certificate Of Installation
Company Name (Installing Subcontractor, General Contractor, orBuilder,�vrQ: En rg�r Raters Asso�ciat on
Burgeson's Heating and Air Conditioning, Inc.
Responsible Builder or Installer Name:
CSLB License:
Kevin Burgeson
263871
HERS Provider Data Registry Information
Sample Group Number (if applicable):
Dwelling Test Status in Sample Group (if applicable)
316-15112
Tested
HERS Rater Information
HERS Rater Company Name:
Mandos Ducts
Responsible Rater Name:
Responsible Rater Signature: ) n1a1y2)0 WC /i /1
Armando Ulloa-Rocha
AR/MANDOROCHA(Feb 25.2016
Responsible Rater Certification Number w/ this HERS Provider:
Date Signed:
HERS
2016-02-25
TA1
"This drgital signature is provided in order to secure
% J the content of this registered document, and in no
1 s L way implies Registration Provider responsibility for
the accuracy of the information.'
U.S. Energy Raters Assoclatlon
Registration Number: 316-A1020161A-M25005433A-M25B Registration Date/Time: 2016-02-25 16:13:22 HERS Provider: USERA
CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.007 Report Generated: 2016-02-25 16:15:15
2013 Residential Compliance Schema Version: 2013.1.007