HomeMy WebLinkAbout974 TRABUCO CIR - Building Permits(714) 754-5273 • Fax (714) 754-4858 • www.ci.costa-mesa.�y�DING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626
JobAddress: 974 TRABUCOCI
Suite:
Viciniry: ROOF
Primary Occ: R3 Dwellings/ Cong Res <10 Type of Consiruction: V-N
Parcel Number: 42205209 Zoning:
Applicant: BLANKS, JERRY
Address: 17501 NORWOOD PARK PL
TUSTIN,CA
Phone: 714-573-0155
Zip: 92780
owner: MITCHELL, TIMOTHY MICHAEL
Address 974 TRABUCO CIR � � ' .
Phone:
- COSTA MESA, CA � - . Zip:- - 92627
Contrector.. � PREMIER ROOFING AND BUILDING CO INC
Address: ' 17501 NORWOOD PARK PL
� � � Phone: 714-573-0155
Arch :
Address:
Zip:
TUSTIN, CA
Zip: 92780 ; .
� � Phone:
License:
License: 634404
Eng:
Address:
Status: ISSUED �
Applied: 02/13/2006
Issued: 02/13/2006
�
ISSUED 8Y:
Phone:
License:
SCOPE OF PERMIT
TEAR OFF EXISTING ROOF. INS7ALL 1 L4YER OF 30# FELT, 50 YEAR COMPOSITION SHINGLES, AND REPAIR/REPLACE SHEETING AS
NEEDED. 19 SQUARES INCLUDES ATTACHED GARAGE. �
FEE SUMMARY
Plan Check: $0.00
Permit: $153.25
SMIP Res: $0.76
SMIP Com: $0.00
Other. $0.00
Inspection: $0.00
Total: ' . $154.01
PLANNING & ZONING
SETBACKS
MAINSTRUCTURE Front �0�0 �. - .,,Rear 0-0 Lefl . 0-0 � -
�. ;
ACCESSORY�, -Front ' 0- 0 Rear 0- 0 Left 0- 0=
� ., j
PARKING �-�� Existina:"�� 0� Reauired: 0 Pronosed: 0
Calc Valuation:
Claim Valuation:
Right 0-0
Right - 0- 0 .
$�,soo.00
$7,600.00
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord. No. 92-28, § 1, 12-27-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abantloned
tor a period of 180 days.
INSPECTIONS: In order for the work authonzed under this permit to be considered legal, such work must comply with all applicable codes, and all
requlred Inspeetlone and final appraval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
IFOR INSPECTIONS CALL: (714) 7545626
244fii6IN00) - - _ -
WORKERS'COMPENSAnON DEGLARAnON:�� � � .
I hereby aflirm under penalry of perjury one oi thAfollowing tleclarations:
❑ I have a�d will maintain a certificate oi consent to self-Insure tor workers' compensation, as provided tor hy seclion 3700 oi Ihe Lebor Code, for tha pertormenca oi the
dt,to hich this pertnit is issuetl.
� 1 have a ill mainlain workers' compensation irlsurance, as �equiratl by secGon 3700 oi the Labor Code, for the peAortnance of Ihe work tor which t is pertnit Is Issuetl_
[Tg:wmpensatlon Insurance wrd✓elr antl policy number are: 9 ��_ � O
�artier. ;,�/sr%TE ��—�e/ PolicyiNumhe � ! �� / a `5
ct(on need not be complet tl il the permif is valued af one bundred dollars ($100) or less.)
❑ � cenity tnat in me pedorm of the work for which Ihis pertriit is iuueQ I shall not employ any person in any manner so as to become sublad to tha workers'
compensation laws of Cali nia, and agr th I s Id become suD'ect to ihe workers' compensation provisions of Saction 3700 of the Labor Code, I shall forthwith
comply with t esa�proq; �, . . /��/D�
ant5ip aWre: 3{°.�=`�- Date� �•
:i� �r.,--
� �NA�IGiF E TO SECURE ERS' COMPENSATION CAVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EM OYEPC R TO GRIMINAL ENALTI AND CIVIL FINES UP TOONE HI/NDFED
YAOUSANDOOIIARE(5100,000�.� ADDITIONTOTHECOSTOFCOMPENSATION,DAMAGESASPROVI�EDFOflIN5ECT10N31060FTHELABOHCODE,INrEREST.ANDATTORNEY'SFEES.
LICENSED CONTRACTORS DECLARATION:
Chapter 9(commencing with Section 7000)
Code, and my licensa is in tu11
GONSTRUCTON LENDING 7�GENCV:
❑ I hereby aHirm that there is a cons�mction lentling agency tor the peAormance oi ihe work for which ihis pertni� is issued. (Sec. 3097, Civil Cotle).
LendeYs Name: Lenders Adtlress:
Signawre: Date:
O�NNER•BUILDER DECLARATIONS:
I hereby ettirm that under penalry oi perjury thet I am EJ(EMPT FROM THE CONTRACTORS LICENSE LAW for Ihe following reeson (Sec. 7031.5, Business and Pro}esslons
Gode: Any city or county which requires a permit to consiruct, atler, improve, tlemolish, or repair any structure, prior to its issuance, also requires Iha applicant for such permit
ro file a signed sletement ihat he or she is licensed pursuant to the provisions of the Contrectors License Lew (Chapte� 9(commencing with Section 7000) of Oivision 3 of ihe
gusiness and Pmfessions Gotle) or thet he or she is eaempt thereFrom antl the basis for the ellegetl eaemption. Any tioletion ol Section 7031.5 by any applicant br a parmit
subjecis ihe applicant to a Civil penalry ot not more than five hwWretl dollars ($500) J�.
❑ I, as owner of t�e property, or my employees with wages as ihelr sole compensetion, WILL DO 7ME WORK, and lhe sirucWre is not iniended or oHered for sale (Sac.
7044, Business an0 Professions Cotle: The Contractors License Lew tloes not apply to an owner of property who builds or improves thereon, antl who doas such work
himseli o� herselt or thmugh his or her own employees, providetl that such impmvemems are not intended or oHered for sale. H, howaver, Ihe builtling or improvemem is
sold within one year oi completion, the owner-builder will have the burden of pmvinq ihat he or she did not build or improve for purpose oi sale.). �
[] I, as owner oi lhe property, am E%CLUSIVELY CONTRAC7ING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business entl Protessions
Cotle: The conirecfors License Law tloes no[ apply to an owner of property who huilds or improves thereon, antl who contrects tor such project with a contrector(s)
license Oursuam to Ihe Comrectors License LawsJ.
p I am exempt untler sec. Business and Professions Code for this reason:
5ig�aWre: Date:
pwner ID verifietl by drivers license. ❑ Ves ❑ No Driver's License No.
Verilication of Ownership by (type oi document, i.e. - properry ta: bill or tleed):
O�YISION OF INDUSTRIAL SAFETV PERMIT CERTIFICATION:
Expires:
❑ I hereby cenify that no excavation five (5) or more taet in depth inio which a person is requiretl to descend, will be made in connection wit� work euthorizatl by Ihis
permit, ana that no building struciwe, scallolding, lalsework, or demoli�ion or dismantling thereoi, will be more Ihen thirty-six (36) teei high. (Chap. 32, Grp 2, Art 2, Sec.
347, Title 8. Califomia Adminisirative Code).
p As owner-buittler, 1 will not employ anyone to tlo work whicn would requira a permit f�om the Division ot Indusirial Safety, es noted above, unless such parson has a
permitto do such work from Ihe division.
5ignature: Date:
Division of Indusinal Safery Permit Number.
CER7IFlCATE OF COMPLJANCE AND AUTHORIZA710N OF ENTRV: I certify untler penalty ot perjury that I have reatl this applicalion and state that ihe infottnation qiven is
'carrect I agree to wmply with all stete laws end city ordinances relating to builtling consiructioq antl authorize representalives of Ihe Ciry of Costa Mesa �o enter upon �he
eDo�e-describe�d properry for inspection purposes. I agree not to occupy or ellow occupancy of eny building authorized by this permit until final inspection.
1616
izss
200
201
202
203
204
INSPELTION TYPE
FixeO System Final Fire Prevention
Pool Spa Final
Final Re-Root
Final BIocWRetaining Well
Final Factory Fire Place
Final Sign
Final Demolltion
P� INTff1AL5
COUE� INSPECPONTYVE
206 Final Mechanical
208 Final Plumbing
210 Final Elecirical
212 Final Fire Prevention
220 Final Planning Approval
222 Flnal Si�6
250 Finel Building/Occupancy
0
' ^ . � - - . �aC� �r Applicant to fi11 in all spaces except those within heavy eorCer lines ana sign all appropriate aeelarations.
" � • '`%�' J � PERMIT NO. � TRACT NO. �: � LOT NO. UNIT NU�
y CITvoF'COSTA -"CO T UCTION:P R �r G�3��L � �Sqy
^ ProjecbAtldreu � _ _ � �' �� - .
ApplicanYsMaili gAddres ' � } J ;
Owner's Name �' U �_.� .. �7� �� �A[� ��phone
, Address , - � ' ;.
Arch/Eng. - � � � �cense'No ' ' •
l � ;
PEldress ' ^ � �
p�7{��� r
Coniractor's Name - Phone �
Address (ma�l�ngl 2� � ��9--- f�
} �`�04� -�: �
City License No.
� LICENSED CONTRACTOR DECLARATION .
1 hereby afti�m that 1 am li<ensetl untle� provi5ions of Charter 9�(commencing '
with sec[ion ]000) ot Olvision 3 of tM1e Business antl Profe¢sions Cotle, antl
my licenze is in tul1}A�o rce pntl effect. ' ^/� ��^� •
i icens CIaSs Y` 1 � /�Y LlFens�No. �'N'}'��� v
; �—�O ���q ���/ .c�C�..�� !
RKERS'COMPENSATION DECLARATIOf�� �
..rereby affi�m tM1at I h �Y�r}�- onsafrt to seli-insu
of Workers' co p� In � eF a certitietl copy e ection
3800, �ab J � ��C � '�}. �
Policy No. Company �^+" -
�Certified copy i5 hereby furni5hetl. � "
M Ce�tqietl cppY �S1Ue�A `xAPPlredaiy Buil ing Divis . �� i
^1/ Date L�" l GSi�� ; . .
� EXEMPTION FROM WORKERS' COMPENSATI N DECLARATION
(This sec[ion neetl not be completetl if the permit i tor On¢ huntlr¢tl ($300) or '
� iess). - . . ,
I certify that in the periormance of the work for which this perm�t is issued; I'
� shall not employ any person in any manner so as to become subject to the '
Wo�kers' CompensatiOn Laws of Caffomia.
I Date Signatu�e �
� NOTICE: If, after makinq this tleclaration, you shoultl become subject to tbe
Workeri' Compensation provisions ot the Labor Code, you must forthwlth
comply with such provisions o� this permit Shall be tleemetl rewketl.
CONSTRUCTION LENDING AGENCV
1 nerety affirm that tnere is a construction lentling agency tor the pertormance
of the work for which this permit is issuetl (Section 3097/Civ. C.)
Lentler's Name �- '
Lentler's Adtlress
,� OWNER BUILDER'DECLARATION �
� .Ichereby affirm that I am exempt from tne Gontracror's License.C.aw for the .
, � �qllowin9 reason.(Section ]031.5 Business antl Professional Cotle: Any city or
703L5 byZ
pYe�nalty of no
� LJ I� d5 OWf
compensatior
� for sale (Se�
License Law
thereon, antl
employees, 0
sal¢. If, howi
pletion, the�i
p�ove tor tne
❑ 1, as owm
�equires�a-pe�mit to construCt, alter, �mprove, tlemolish or repair
prior to its issuanc¢, alm requi�es tM1e applicant tor Su<h pe�mit
tl staiement that he/she is Ilcensetl pursuant to the provisions ot
r's License Law (Chapter 9(commencinq wi[h Section �000) of
the Busine5s antl P�ofe55ion5 Cotle) o� tha[ he/sne is exempt
] the basis fo� the alle9etl exemption. Any violation of Section ,
applicant for a Permit subjects the applicant [o a civil
. re lhan tive huntlretl tlollars (E500).
.r o he property or my employeez with wages as their Sole
, will the work, antl the structure is not intentletl or offeretl
[ion 704 Business antl� Professional Cotle: The ContractoYs
1oe5 not dp [o an owner of a property who builtls o� im0/ove5
who tloes suc work himself/herseli or through his or her own
oviEetl thai su[h ptovemen[5 are nOt intentletl or offereC to�
ver, the builtling o� � provement is soltl within one year of com-
wner will have the bU en ot p�oving he/she tlitl not builtl o� im-
purpose of sale).
r of the pro0erty, am exU vely contractinq witti licensed con-
istruct tne project (Section 7 4, Business antl Protessions Cotle:
or's License L.aw does m[ aDP to an owner of property who
�TYPE OF,CONSTRUCTION ' NEW ADD ALTEfiATION REPAIR�
jOCONVER510N ❑.DEMOLISH OTH�EWi
��`p* E�C_p1IPTION WO USE OF BLDG. 1"`�� ������
. J� ��f - � ' �
r�
TVPEOFPERMIT ❑GRADIIVG ❑FOUNDATIO � STRUCTURAL
O'TENANT �ELECTRICAL�PLUMBING �MECHANICAL
'O OTHER
.rPRO�ECT DESCRIPTION . ^5p� p7'' nrr� Pn�tif�v =�
,• CONSTRUCTION T,VF6�T� vni IInTInN ¢ G..S�
' �.20NE � GRADINGCV.VDS. ACRES
Preventer
Irri9ation
iking Fountains
�r Orains
�r Sinks ` �
Service (
rceotors . , ,
Kitchen Sink,
Cavatories
F-Trap ' — .-
Roof_Drains S ,.
Rainspec[ion Fee
Boiler
Duct - Under Ground
Duct - Structural
$75
builtls or improves thereon, antl who mnVacts r suth 0/o�EctS wrth a com � •
[rd�tor(s) Imense pursuant to the Contractor'S Lire e Law). I am aware (hat ExhaUst Sy5[¢m ❑�Multipl¢ ❑
o�oo( of their Wo�ker's Compensation insurance sho tl be provitletl to me. ___
❑ I am exempt untler 5ection B. &. C. for this reason FirepUF.ac4. Blt. ICBO #
Date Owner ' Heating System & Ducting
1 hereby certify that I have reatl tnis application antl state that e above ❑6100,000 BTU �100,OOOBT
into�mation is � rrect. I agree to mq{y with all City�antl county or "nances
antl s[ate laws r lating to buiitlii ry Jructian, antl hereby aut orize Dre-
sentatives of th city o ente oi e�ab ve-mentionetl o ert tor
inspectlan pu po es. �/
Siqnature ODate i peinspeetion Fee ' $15
Drivers' License r 55 � �
CMF 0865-46, rev. 10 B4 Wnite - Builtlin9; Canary - qpplicant; Pink - Accounting: Goldenrotl - Assesror
Showers
Service Sink
Sewer Cap
Solar Pipin9'� i
Solar Tank�
Swimming Pool w/Spa
Urinal
Water Closet
Water Heater
Water Service
Auto=Wash ' -
Laundry,Trays
Issue Fee
Hood or Typel ' ❑
Canopy Type I I ❑
Refrigeration Sysrem
❑o-ioo,000sru ❑ioo,000
System Repair/Alteration
Fire Oampers
Registers ' �
Issue Fea
r. ,
$ 3
A.P. # ']r �
S Main Building:
E
T Fmnt - . a.(-
ARear �
C Right
g Left �
Ping. Ref. #
Planning Notes: P *
Automatic Washer
Construction Pole Sub.
Cooking Unit
Dishwasher ,
Dryers ❑Gas ❑Elec'
Fan
F.A.U.
Fiztures �
Device Boxes
Zone
Parking Req./Provided
ux- • pvi.0 r V1C JCCI:IAL 1
ELECTRICAL
Transformer ❑ 15-W KW
0 50 + Kw
SwiLcheS
Garbage Disposal
Generator 065 KW (-'J5-75 KW
Meter LJup to 100 amps
Meter ❑over100amps
Sub Panel
Morors �0-1 HP 01 %- 8
InaSolar 09-75 HP ��i6-15+
Microwave
Pole Light
Range
'Standing Sections
Trash Compactor
FEES
Z
O
N
I
N
G
R
E
Q
M
� Reinspection Fee '$15 � � Issue Fee �"$T�
DEVELOPMENTSERVICESREQUIR MENTS:
Zoning Approved By Date ' 2 Z� 5
Building Appraved By - ` Oate
Application Issued By Date
� � SUMMAR�F FEES c`b
BUILDINGPERMIT $ %�R�_�" SMIP $ �
PLAN CHECK � g PERMIT ,
PLUMBING § ��.(� � ISSUANCE $
PLAN CHECK 25% $___�b_ ENERG� P.C. $ �
EIECTRICAL $ �� ..� GRADING $
PLANCHECK 50% $ MICROFILM $ �
MECHANICAL $ �—� �_ TOTAL FEE $ �
PLAN CHECK 25% $
� _
� ,. .l >
� CONSTRUCTION AND PLANNING �� �• � , . � POOL & SPAt' • - .
; � Date �,Inspector � Date �,Inspector
APPROVALS IP,ermit #' �� l;� c• APPROVALS Permrt #_ :�
. I.''
' 1: �Temporary Electrical Service or Pole , 52. Pool & Equipment Location _ r�
!r v lJ
� 2. Soil Pipe-Undrgrnd. � , 53. Steel Reinforcement' �'1 � �-
i�
� _,
3. Electrical Conduit Utility-Undrgrnd. 54. Forms
4. Electrical Conduit-Undrgrnd. . . 55. Electrical Bonding '.:, � ' � � � � �
' 5. Steel Reinforcement -�, - 56. Rough Plumbing & Pressure Test ' � '
r
6. ElectricalUFERGmd. �- 57: APPROVALTOCOVER:GUNITE � '
� 7��Footings '• ' y G� 58. Electrical Conduit-Unilrgrnd. ;
�. i� ii ,
S..,Foundativn �'� � . � 59. Gas Pipe, � Undrgrnd�, Test
9 Water Pipe-Undrgrnd. �'! 60. Backwash Lines, P-Trap, � Undrgrnd. ;��' ,- �
,�.
�10. �Structural Floor System ..�% ' 61. APPROVAL TO DECK� � � �"
._�n 4� �
- 11. Property Sewer Line & Hou`se Connection q2y �,� L� 62. Backwash & Receptor-Final �� - C' �,�� �
�
12. �Sewer Cap . ' 63. Heater & Vent-Final � . q �� � . � � �
13. Roof Drains . � - 64. Plumbing System - Finaly� �✓ f11 `
�, !� � . _,}:�- �'J .
14, Rough Plumbing � �_Zy_�y , LF.O 65. ElectricabFinal � � ✓ • � �!
15. Rough Electriral-Conduit • 66. Solar SYstem-Final ��� �
16. Rough Electric Wiring �•� � 67. Fencing & Access App�oval �
17."Rough Wiring 5ign G � - '
. � � j�,, �j �1 �y 68. APPRO,�V,ED POR;NPL'RSTERING ��,
�18!sRough Electr�icral-T Bar Ceiling j� -�: � 69. POO.L/SPA SYST�MS FINAL� �L� ('i '-? - +�
, �19. Rough Heating & Air Conditioning ` rfy�� (�p FIRE DEPT. REQUIREIVIENT Q�- . ; I
20. Rough Factory Fireplace . APPROVALS .Permit# n �-'� � �
it � '
21. DuCts, in Structure � � � 70. Underground Hydro _ n ���� ' r... � �
22. Ducts, Ventilating , �, 71 . Product Piping � Gas � Oi� ' �/ Q�� '� .
23. Gas Pipe-Rough & Test � � 72. Underground Flush i� �-�� �� �• „j ���
24: Roof Framing ' _ . � ' 73�. � Undergrnd, Storage Tank �•Gas ❑ Oil � � � j `' � � �
, 25. Roof Sheathing. �N. 74. Ov`erhead Hydro - � . �-� � _ n � , •� �
26. T-Bai Ceiling,�Structurap & Monocoat �'• � � 75.. Dry Chemical �- (°� . (�J � � , �, ,r1 :
27. FrameandFl�Shing .. � � 76. DryStandpipe - �
i� �'v i� ' �fi,
� 28.. Lathing & Siding�- � � 77.. FIXED SYSTEM FINAL` l� 1.''�'�� y�%
i,
i
29. Insulation �Y . 78. FIRE PREV. FINAL � I� ,� ;"�� �
30. Drywall Nailing f/ . (p �� � HEALTH DEPT. RMQUIREMENT � �� �� -
31'.� Plaster Brown Coat � . � � i �� �y,, 79. FINAL WSPECTION � � �' , � � �� :�.��;t.;p:� ,U _
32. Electriral Power Meter:Final - 80. FOOD�CERTIFICATE ISSUED �•��,; �/
33. Final Electric ` ' - 7_�� Notes:l F �� t ��� �d t
34. Finaf Heating.& Air Conditioning ' ��_�S� L�) N � � t S- ,-t�--,
� 35. Final�Gas Pipe-�st' � '• � � , /�1 � ' - � � �
ti
36��Hood or�Canopy� � _ € pn�, ' ��" � �v
-1 7
z 37�Final Factory Fireplace � , � � - ' � ) �� �
... . .\��.ti' R N" �n�(O�
367Finel�Plumbing .�� . � /I-N'YY L� �\ .n � � � � � � � ✓ p. A .
..o-- .
�
- 39 � Water Se` ice-Final � - '� f�1 `��-17 � �+ � �-�n�-� -
A 77 u'{
�:.40. Gas Service Final ' ' ' =' ` -
1„. V •� � n CCI I� ," ,��
� � . .���1 ''1� L �.,r.r
-y41n� Solar pomestic\Final ' � . - � �`,�� � l '� ,i �P /V �
ti42�BackflowPrevenier - � ` ✓'� � (f��!' n, ^: ,. � �
�' "• ♦ �7 �
�� - � �
.�43=8ackflow Irrigation\ . r `� �, �,,. �^ � I � _'�.�.
� .
•_,�44`uL•andscape,irrigation Sys�em - � `"' � �'7j v ,. �a � �I ��,b J �
�W5. Sound Attenuation \ . � ~ � L N� �� (�, `� t
i
46.lHandicap Regulations ' \ . " ' rU =Z'=�1 �i `�>, '�%
�/n._
� 47. FINAL STRUCTURE & BUILDING 2 . � �� � � �Yj T� �.� ' .
� , , r„ ,,,: „rti, � -> 11 ���-. �_
�-48rSpecial RequirementsCompleted \ � . �� . � I� � _ � � ' � �^ � ' 1:' •
Y
49. Electric Release to Edison - . �' •� � r . � ( � ,+ � � �
� � � �• � , '�•.
50. Gas Release to Southern California Gas Co \ � � "" ., � � ' � }�'"''
-b l:.; . :
51: CERT!FICATE OF OCCUPANCY -. � � � � . ' - .'/�.._� •
�. � r�. • . -°i ... ;
No. ' •'Date - _ _ - ��; .. . i � .. � '. ;,r.-'_ _ � _. ' t .,-i
�� r � �+� i •'*. - •
. --
� Z/L/S'�. .
_ _ _ - - - --- -- - - -
%f�� ��•t/fIG _ G'�P/r!�i�G i9 � _T__-- --- =- -
-- --- ------ - - - - - - --- - -- --- --- -
q 7�l �►2A�uc�__ C��c.c�c.- - -�.��nuv_s- - -
t� �Z o t��2 'P 2 A[ NA G�-�� -- T//�- -�aPa J'�'!2T'/,
--- -.��-�''----.------ - --
G',�,�y -��zo��
- - - - - - - -C�lcir�v�,�i.� — ,��noaE �1 NG -
�TY OF C S' 'A ME�
LIFORNIA 92628-120D P. O. BOX 1
Insulation Certiticate •
9�y ���a��� �_� ���-�
Numbu and Street City
���tiv G�
cowty s��ri��, �� x�,n��
ROOF
Material
Thicl�ess (in�h s)
/
EXTERiCR WALL �j
Material %J�"%J
'ILickness(inches) �� %
Description of Installation
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G�rr
BrandName /y%� �/G�
7t�ertnal Resistance (R-Value)
CEILING /�
Batt or Blanket Type [JfJ-�T Brand Name �/�/� !/�G�-�
'Ihidmess (inches) � "' 'Ihem�al Resistancc (R-Value) �-' -/ �
Loose Fill T Brand Name
Contrac[or's minimum installed weight/ft Ib Minimum thiclrness inches
Manufachuei s installed weight per square foot to acheive'Il�ermal Resistance (R-Value)
RAISED FLOOR
Material � — Brand Name /�-
'Ihickne '�sr 'Ihertnal Resistan - al
� i
SLAB FLOOR
Material �- { Brand Name /- ��
Thickness (inches)/ J `_ Thertnal Resistance (R _Valu� /
Width (J s)� / �-` '
�
FOUNDATION WALL
Material Brand Name _
'Ihiclrne�c�5 'Il�ertnal Resistance (R-Y ue) /
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Declaration
I hereby certify that the above insulation was installed in ffie building at the above location in confoimance with
the curren[ Building Energy Efficiency Standards for new residenual buildings contained in Tifle 24 of the
Califomia Administrative Code. �— �//,0�� �
7
Li Number
�i������e
Date
Sub�Contracwr(Insuletionlnstaller) —
Liceme
Signanue ud Ti[le Dale
Nov 2 9 �saa