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� D�,1>�111ND BARt
CITY OF DIAMOND BAR O
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@diamondbarca.gov
JOB SITE ADDRESS 13 L
APN LOT TRACT
OWNER
ADDRESS ' AA5l1
CITY 1) ZIP 4114 i TEL. 4 M ." if f 3X_9
APPLICANT Z 6-ptyhtia.f/ TEL. "7'9. 'r-7kV
CONTRACTOR 4 e
ADDRESS
CITY rb pue 1 ZIP (7f L.
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, atter, 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).
L) 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.).
L)1, 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' Slate
License Law.).
L) 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 Cade 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 farce and effect.
LICENSE CLASS: LIC. NO.: 61 D 3 PJ
DATE: CONTRACTOR: 4 �
WORKER'S COMP ISATIOIVDECLARATION
r
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 Number are:
CARRIER L
POLICY NUMBER W ?'I.
(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 provision of Section 3700 of the Labor Code, I shall forthwith comply with those provisions.
DATE: nPPLICANT:
WARNING: Failure to secure Worker's Comp�ation c�rage is unlawful, and shall ubject an employer to is unlawful, and shall ubject 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 (PRINT)
SIGNATURE
SIGNATURE ERMITTEE�'
APPLICATION DATE: P/C# /f/n
ISSUE DATE: 91Vf/* PERMIT#: / g///- IJJJ�
TYPE CONST. OCC GROUP: 14A i
Scope of Work
# DWEL. UNITS # STORIES # BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF ADJ. AREAIVALUATION
SFR/ADD/REM
Garage/Carport
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Patio/Deck
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Pool/Spa
ZRe
-Roof
Commercial
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Valuation: Adj. Area:
QUANTITY DESCRIPTION FEE
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CONSTRUCTION:
PLAN REVIEW:
ELECTRIC:
PLUMBING:
�?
MECHANICAL: 7A 6 Z
INSPECTION FEE: l
ISSUANCE:
SMTP:
ENERGY P/C:
ENERGY PERMIT:
RETENTION FEE:��
PRE -ALT FEE:
BASF:
PLOT PLAN:
ZONING CLEARANCE:
TOTAL FEES 13-.2331
COMMENTS:
P/C: q y ^7 PAID BY: VALIDATION:
RECEIPT a PAID BY: VALIDATION: '`-
WHITE —Department Copy, YELLOW —Finance Copy, PINK —Assessor Copy
CITY OF DIAMOND BAR
INS'RECTION 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:
ir,
INSPECTION DATE
O.
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( )'2ND( ) 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.
CEC-CF I R -ALT -04-E (Revised 061141 . , CAU-OR"+IA ENERGY COMMISSION
CERTIFICATE OF COMPLIANCE CHR -ALT -134-E
i Alterations - HVAC CZ 2, and 8-15 (formerly CF -IR -ALT -HVAC) _ (Page 1 of 1)
^I[? Address:
I
Equipment Type I Equipment Efficiency
❑ Packaged System i CrEvaporator Coil I
AFUE
11 Split System C�'Condensing Unit
❑ Mini Split ❑Compressor SEER
Ifiurnace 11 Lineset EER j
1-1 TVI!
f1 c
New Ducting, Pienums, Lineset:
Required R -value
COP ' ❑ R-6 (CZ 2, 5-13) Ducting
❑ R-8' (CZ 11, 14, 15) Ducting
HSPF ❑ R-6 (all CZ's) Plenums
❑ R-5 or R7.5) Lineset
1
l.Qn �IIV ned
Thermostat
Floor Area (sq ft) 1 i
Served by system
❑ Setback
sqft (if not already
present, must
j be insta;led)
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
❑ 1. HVAC Changeout/Repair Required Compliance Documents to be left on site for Final:
All Equipment,
CF1R-ALT-02-E
Condenser Unit, Evaporator Coil,
CF2R: MECH-01, MECH-20-HERS, MECH-(23 or 24)' -HERS, MECH-25-HERSZ
Compressor, TXV, Lineset,
CF3R: MECH-20-HERS, MECH-(23 or 24) -HERS, MECH-25-HERS2
Air Handler/Furnace2 (Can include new ducting)
Installer Requirement: Duct leakage (<15%, or < 10% to outside, or seal all accessible leaks), Air Flow >_ 300 CFM/ton, Refrigerant Charge.
Exempted from duct leakage testing if:
111. Duct system registered with HERS provider as previously sealed, or ❑ 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 Documents to be left on site for Final
All new equipment and All New Ducts3
including Mini Split
CF1R-ALT-02-E
CF2R: MECH-01, MECH-20-HERS, MECH-22-HERS, MECH-(23 or 24)-HERSZ, MECH-25-HERSZ
CF3R: MECH-20-HERS, MECH-22-HERS, MECH-(23 or 24)-HERSZ, I41ECH-25-HERSZ
Mini Splits require CF1R-ALT-02-E, CF2R-MECH-01, and (CF2R-CF3R) MECH-25-HERS
'
Inst er Requirement Duct leakage < 6%, Fan Efficacy (.58W/CFM), Air Flow ? 350 CFM/ton (or alternative), Refrigerant Charge
3. All New Ducts with Replacement Required Compliance Documents to be left on site for Final:
All New Ducts' and one or more of the following
CF113-ALT-02-E
replaced: Condenser Unit, Evaporator Coil,
CF2R: MECH-01, MECH-20-HERS, MECH-(23 or 24) -HERS, MECH-25-HEP,S
Compressor, TXV, 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: ❑ 1. Existing duct systems are constructed, insulated or sealed with asbestos
❑ 4. New Ducting over 40 feet Required Compliance Documents to be left on site for Final
New ducting but less than All New Ducts3 CF1R-ALT-02-E, CF2R: MECH 20 -HERS, CF3R: MECH-20-HERS
Installer Required to: Dud leakage (< 15% or, < 10% to outside or, or seal all accessible leaks)
❑ EXCEPTION: Existing duct systems constructed, insulated or sealed with asbestos.
' All new ducting R-8 required when more than 40 ft installed and R-6 when less than 40 ft installed. This includes in walls, between floors etc.
' Heating only systems and Air Handler/Furnace changes do not require Air Flow MECH-(23 or 24), or Refrigerant Charge verification MECH-25
3 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 handler, coil, plenums, duct material)
R-5 (1" thick insulation) for linesets 1" and less. R-7.5 (1.5" thick insulation) for linesets over 1 inch. Most mfg will require Suction line Diameter
with insulation as the following 1.5-2T-2%", 2.5-3T-2%", 3.5 to 4T-2%", 5T-4%8"
Contractor (Documentation Author's /Responsible Designer'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 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).
i 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. j
{ 5. 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.
Responsible Designer Name:
1xf
Responsible Designer Signature: Date Signed: License: e
3�J
Coany :
mp
Addres City%stateAZip: Phone: f
' 3
i A - Avb 1
For assistance or questions regarding the Energy stanciarcis, Tntact ine tnergy nornne ar: i-ovu-i,c- —V—
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: �
Ian Jacoby
can dacobJc
Company:
Date Signed:
i PERMIT E RATERS
2016-06-02 17:20:52
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 tate
he Certifics) of¢Installatiorig(CF2R)�signedsand3submittedBby the person(s) responsible for the
construction or installation conforms to the requirements speafiedon' the Certdicate(s) of Compliance (CF1R) approved by<Yhe enforcementhagency.
S. I that`s registered this Certificate Verification shall be or made,available with the'f6uilding issued for the
will ensure copy of of posted permit(s)
building, and made:available'ao the,enforcement agency for all pplicable.inspections. I understand that a registered copy of this Certificate, of
.,. W.,.�. _ aa:
Verification is required to be inclu'de'd with the documentation the builder"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):
A - AVIS PLUMBING HEATING & AIR CONDITIONING INC
Responsible Builder or Installer Name:
CSLB License:
Brandy Haeckel
630503
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:
Jonathon Johnson
-
�BlG�G�c�i '�Jl.OB�Yi
Responsible Rater Certification Number w/ this HERS Provider:
Date Signed:
CC2006575
2016-06-02 17:21:05
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-A0204728A-M2000002A-M20A Registration Date/Time: 2016-06-02 17:21:05 HERS Provider: CaICERTS
CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.007 Report Generated: 2016-06-02 17:19:12
2013 Residential Compliance Schema Version: 2013.1.007
J.
CERTIFICATE OF VERIFICATION
CF3R-MCH-23-H
Space Conditioning System Airflow Rate
(Page 1 of 4 )
Project Name: AMY TSUJI
Enforcement Agency: City of
Diamond Bar
Permit Number:
PR160553
Dwelling Address: 1345 ROLLING KNOLL ROAD
City: Diamond Bar
Zip Code:
91765
A. Ducted Cooling System Information
01
System Identification or Name
System 1
02
System Location or Area Served
Location 1
03
System Installation Type
Alteration
04
Nominal Cooling Capacity (tons) of Condenser
5
05
Condenser Speed Type
Single Speed
06
Cooling System Zonal Control Type
Not Zonal
07
Central Fan Integrated (CFI) Ventilation, System:Status
Not a CFI system
08
S stem B ass Duct Status ''
Y yp
No�B yP pass �
Duct
09
E
Date of System Airflow Rate MAleasurement{
3�:
2016 04 15
10
Airflow Rate Protocol utilized31,,
, RA3 3 p ocedur,,es fo airflowAratejmesurem nt
B. Hole for the placement of a Static Pressure Probe (HSPP), and Permanently installed Static Pressure Probe (PSPP)
in the supply plenum.
Procedures for installing HSPP or PSPP are specified in RA3.3.1.1.
01 Method used to demonstrate compliance with the HSPP installed and labeled consistent with Figure RA3.3-1
HSPP/PSPP requirement
C. Airflow Rate Measurement Apparatus and Procedure Information
Instrument Specifications are given in RA3.3.1.1, and system airflow rate measurement apparatus information is given
in RA3.3.2.
01
Airflow Rate Measurement Type used for this airflow rate
Traditional Flow Capture Hood according to procedure in
verification.
RA3.3.3.1.4
02
Manufacturer of Airflow Measurement Apparatus
ALNOR
03
Model number of Airflow Measurement Apparatus
EBT731
Certification Status of the Airflow Measurement Apparatus
Certified by Manufacturer and listed on CEC Website at
0 4
Accuracy
s
http://www.energy.ca.gov/title24/equipment_cert/ama_fas
/index.html
Registration Number: 216-A0204728A-M2300002A-M23A Registration Date/Time: 2016-06-02 17:21:05 HERS Provider: CaICERTS
CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.007 Report Generated: 2016-06-02 17:20:02
2013 Residential Compliance Schema Version: 0.555SDD
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: �
Ian Jacoby
can dacobyr.
Company:
Date Signed:
i PERMIT E RATERS
2016-06-02 17:20:52
Address:
CEA/ HERS Certification Identification (if applicable):
31225 La Baya Drive #1213
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 section"s`ofthe Certificate(s) of Installation"(CF2R) signed and submitted�by the persons) responsible for the
construction or installation conforms to the,requirements'speci6d 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 withthe building permit(s) issued for the
building, and made available to the enforcement;agenLy for all applicablepections I understand�that a registered copy of this Certl ica
�
Verification is required to be included with the documentation the builder provides to the building owner atoccupancy.
Builder Or Installer Information As ShownOn The Certif cafe Of Installation "
Company Name (Installing Subcontractor, General Contractor, or Builder/Owner):
A - AVIS PLUMBING HEATING & AIR CONDITIONING INC
Responsible Builder or Installer Name:
CSLB License:
Brandy Haeckel
630503
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: --
Jonathon Johnson
Responsible Rater Certification Number w/ this HERS Provider:
Date Signed:
CC2006575
2016-06-02 17:21:05
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-A0204728A-M2300002A-M23A Registration Date/Time: 2016-06-02 17:21:05 HERS Provider: CaICERTS
CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.007 Report Generated: 2016-06-02 17:20:02
2013 Residential Compliance Schema Version: 0.555SDD
CERTIFICATE OF VERIFICATION
CF3R-MCH-25-H
Refrigerant Charge Verification
(Page 1 of 4 )
Project Name: AMY TSUJI
Enforcement Agency: City of
Diamond Bar
Permit Number:
PR160553
Dwelling Address: 1345 ROLLING KNOLL ROAD
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
Location 1
03
Condenser (or package unit) make or brand
GOODMAN
04
Condenser (or package unit) model number
ASXC160601BD
05
Nominal Cooling Capacity (tons) of Condenser
5
06
Condenser (or. package unit) serial number
1512024515
07
Refrigerant Type,
R-410A�
08
Other Refrigerant` Type (if applicable)
z 3;
09
NVA
System Installation Type
Alteration
Charge Indicator Display (CID) Status (Note Even systems
This system does not have a CID device installed
10
with a CID must have refrigerant charge verified by installer).
Is the system of a type that the minimum airflow can be
Yes, this is a ducted system and one of the system airflow
11
verified using an approved measurement procedure (RA3.3
rate measurement procedures in RA3.3 or RA3.2.2.7 can be
or RA3.2.2.7)?
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
12
with the refrigerant charge verification requirements when
used to verify compliance
temperatures are greater than or equal to 55F (RA3.2.2, or
RAI)?
13
Date of Refrigerant Charge Verification for this system
2016-04-15
14
Refrigerant charge verification method used.
Subcooling (outdoor temperature must be equal to or
greater than 55 degF)
15
Person who performed the Refrigerant Charge Verification
HERS rater
reported on this Certificate of Installation
16
HERS Verification Compliance Requirement Status
System does not qualify for group sampling
17
Refrigerant charge verification method used by HERS Rater.
Subcool
Registration Number: 216-A0204728A-M2500002A-M25A Registration Date/Time: 2016-06-02 17:21:05 HERS Provider: CaICERTS
CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.007 Report Generated: 2016-06-02 17:20:35
2013 Residential Compliance Schema Version: 2013.1.007
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: �/
Ian Jacoby
clan Jacob
Company:
Date Signed:
i PERMIT E RATERS
2016-06-02 17:20:52
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 Certificate of Compliance for the building approved by the enforcement agency.
...
he Certifices) of Insfallation (CF2R)�signed a_nd submitted by the persons) responsible for the
4. The information reported on applicable sections.' tat
construction or installation conforms to the requirements,specified on the Certificate(s) gf Compliance (CF R) approved by the enforcement;agency.
S. I will ensure that a registered copy iof this Certificate of Verification shall be pasted -or made€available with the building permits) issued for the
building, and made available to the,enforcement,agency, for,all applicable inspections I understand that a registered, copy of this'Certificafe of
Verification is required to be'included with the documentaiion the builder provides to the but ding owner at76ccupancy.
d
_
17 M
Builder Or Installer Information As Shown On TheCertificate Of Installation
Company Name (Installing Subcontractor, General Contractor, or Builder/Owner):
A - AVIS PLUMBING HEATING & AIR CONDITIONING INC
Responsible Builder or Installer Name:
CSLB License:
Brandy Haeckel
630503
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:
Jonathon Johnson
Responsible Rater Certification Number w/ this HERS Provider:
Date Signed:
CC2006575
2016-06-02 17:21:05
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-A0204728A-M2500002A-M25A Registration Date/Time: 2016-06-02 17:21:05 HERS Provider: CaICERTS
CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.007 Report Generated: 2016-06-02 17:20:35
2013 Residential Compliance Schema Version: 2013.1.007
CERTIFICATE OF INSTALLATION
CF2R-MCH-01-E
Space Conditioning Systems, Ducts, and Fans
(Page 1 of 7 )
Project Name: AMYTSUJI
Enforcement Agency: City of Diamond Bar
Permit Number:
PR160553
Dwelling Address: 1345 ROLLING KNOLL ROAD
City: Diamond Bar
Zip Code:
91765
A. General Information
01
Dwelling Unit Name
AMY TSUJI
02
Climate Zone
9
03
Dwelling Unit Total Conditioned Floor
3000
04
Number of Space Conditioning
1
CFA served
Area (ft2)
Installing a
Installing new SC
Systems in this Dwelling Unit.
Installing
05
Certificate of Compliance Type
Prescriptive alterations (CF1R-ALT)
06
Method used to Calculate HVAC Loads
NotApplicableEquipmentChangeout
07
Calculated Dwelling Unit Sensible
This field or section is not applicable
08
Calculated Dwelling Unit Heating Load
This field or section is not applicable
Name
Cooling Load (Btuh)
System (ft)
ducted
(gtuh )
components?
09
1 Dwelling Unit Number of Bedrooms
5
MCH -01b Prescriptive Alterations - Space Conditioning Systems Ducts an'd Fans
y
r jr
B. Space Conditioning (SC) System Information
01
02
03
04
05
06
07
08
09
10
SC System
SC System
CFA served
Is the SC
Installing a
Installing new SC
Installing more
Installing
Installing
Identification or
Location or Area
by this SC
a
systemsystem
refrigerant
than 40 feet of
entirely new
entirely new SC
Alteration Type
Name
Served
System (ft)
ducted
containing'
components?
ducts?
duct system?
system?
system.
component.
Altered space
System 1
Location 1
3000
Yes
Yes
Yes
Yes
No
No
conditioning
system
Registration Number: 216-A0204728A-M0100002A-0000 Registration Date/Time: 2016-06-02 17:18:30 HERS Provider: CaICERTS
CA Building Energy Efficiency Standards - 2013 Residential Compliance Report Version: 2013 Rev 1.007 Report Generated: 2016-06-02 17:12:50
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:
Jacoby, Ian
can acob
Company:
Signature Date:
i PERMIT E RATERS
2016-06-02 17:17:35
Address:
CEA/ HERS Certification Identification (if applicable):
31225 La Baya Drive #213
City/State/Zip:
Phone:
West Lake Village CA 91362
1818-735-7876
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 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. = �' " e " " """
t
divices.(the applicable the
3. The constructed or installed features, materials, components or manufactured installation) identified on this Certificate of Installation conforms.to all codes and regulations, and
t€E E Ei
"
installation conforms to the requirements given on the plans and specifications,+approved by the enforcement -agency.
°= t,
4. I reviewed a copy of the Certificate of Compliance appro by the enforcement ageney that identifiesthe,specific regwrementsf�or 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.
S. I will ensure that a registered copy of this Certificate of Installation shall,be posted, or made available with the building per issued for=the building, and made,available to the enforcement agency for all
applicable inspections. I understand that a registered copyof this Cert h of Iri`stallati41
on is rewired to be included with tKi documentation the l5uilder rovides to the building owner at occupancy.
PP P g q p g
Responsible Builder/Installer Name:
Responsible Builder/Installer Signature:
Haeckel, Brandy
Company Name: (Installing Subcontractor or General Contractor or Builder/Owner)
Position With Company (Title):
A - AVIS PLUMBING HEATING & AIR CONDITIONING INC
Production Manager
Address:
CSLB License:
600 EAST VALLEY BLVD
630503
City/State/Zip:
Phone:
Date Signed:
12016-06-02
COLTON CA 92324
1909-825-3600
17:18:30
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-AO204728A-M0100002A-0000 Registration Date/Time: 2016-06-02 17:18:30 HERS Provider: CaICERTS
CA Building Energy Efficiency Standards - 2013 Residential Compliance Report Version: 2013 Rev 1.007 Report Generated: 2016-06-02 17:12:50
Schema Version: 2013.1.007