11050160CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19676 STEVENS CREEK BLVD
b""NER'S NAME: KCR DEVELOPMENT
CONTRACTOR: PHOENIX SIGNS PERMIT NO: 11050160
446 QUEENS LN DATE ISSUED: 05/20/2011
4ER'S PHONE: 4083431088 I SAN JOSE, CA 95112 I PHONE NO: (408) 573-9300 I
❑ LICENSED CONTRACTOR'S DECLARATION
License Class��JJ�! Lic. #__( 470
Contractor HUA, :4-r R Date��hapter
I hereby affirm that I am licensed under the provis
(commencing with Section 7000) of Division 3 of the Business & Professions
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self -insure for Worker's
Compensation, as provided for 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 provided for by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
APPLICANT CERTIFICATION
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 city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
with all non -point so rce regulations per the Cupertino Municipal Code, Section
9.18.
Si mature Date Zl
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
I, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec.7044,
Business & Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three
declarations:
I have and will maintain a Certificate of Consent to self -insure for Worker's
Compensation, as provided for 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 provided for by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
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. If, after making this certificate of exemption, I
become subject to the Worker's Compensation provisions of the Labor Code, I must
forthwith comply with such provisions or this permit shall be deemed revoked.
APPLICANT CERTIFICATION
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 city to enter
the above mentioned property for inspection purposes. (We) agree to save
:unify and keep harmless the City of Cupertino against liabilities, judgments,
s, and expenses which may accrue against said City in consequence of the
b..mting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
MECH r RESIDENTIAL r COMMERCIAL r
JOB DESCRIPTION: DR. KELLY QUACH'S CHIROPRACTIC CLINIC - INSTALL
ONE SET CHANNEL LETTER SIGN ATTACHED TO WALL
Sq. Ft Floor Area:
Valuation: $3004
APN Number: 36906009.19676 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by: - Dater Z 6r' r'
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
Signature of Applicant: Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(x) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safe:y Code, Sections 25505, 25533, and 25534.
Owner or authorfqd agent:
Date:
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of wrk's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
I Licensed Professional
Signature Date
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19676 STEVENS CREEK BLVD CONTRACTOR:PHOENIX SIGNS PERMIT NO: 11050160
OWNER'S NAME: KCR DEVELOPMENT 446 QUEENS LN DATE ISSUED:05/20/2011
OWNER'S PHONE: 4083431088 SAN JOS>;,CA 95112 PHONE NO:(408)573-9300
❑ LICENSED CONTRACTOR'S DECLARATION r r
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class �%� Lic.#
MECH r RESIDENTIAL r COMMERCIAL F
Contractor Date f
I hereby affirm that I am licensed ander the provisions of Chapter 9 JOB DESCRIPTION:DR.KELLY QUACH'S CHIROPRACTIC CLINIC-INSTALL
(commencing with Section 7000)of Division 3 of the Business&Professions ONE SET CHANNEL LETTER SIGN ATTACHED TO WALL
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided for 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 provided for by Sq.Ft Floor Area: Valuation:$3004
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
APN Number:36906009.19676 Occupancy Type:
APPLICANT CERTIFICATION
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 city to enter PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION.
granting of this permit. Additionally,the applicant understands and will comply
with all non-point so rce regulations per the Cupertino Municipal Code,Section
9.18. / Issued by: �� `' ' Date:,
Signature Date rs i
❑ OWNER-BUILDER DECLARATION RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
I hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for
the following two reasons: inspection.
I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044, Signature of Applicant: Date:
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(See.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three
declarations: HAZARDOUS MATERIALS DISCLOSURE
I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(x)should I store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,I Owner or authorL-ed agent:
become subject to the Worker's Compensation provisions of the Labor Code,Imustr�/ — Date:__ ///
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of«ork's
I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
Licensed Professional
Signature Date
CITY OF CUPERTINO
CUPERTINO PERMIT APPLICATION FORM
APN#
0 Date:
5/16/11
Building Address:
19676 STEVENS CREEK BLVD, CUPERTINO, CA 95014
Owner's Name Phone#:
DEAN k 408-343-1088, EXT 8111
Contractor: License#:
HUNG TRAN P 924806
Cupertino Business Licens,e#:
Contact: HUNG TRAM - x -7
Building Permit Info:
Bldg El Elect
Job Description: INSTALL ONE SET CHANNEL LETTER SIGN ATTACHED TO WALL.
(DETAILS SHOWN PER DRAWINGS) f C
Residential: ❑ Commercial: RX
Cost of Project: Monument: El Mounted on Building: Xx
$ 3, 004
Qty. if
Applicable Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BSEISMICOM Seismic Commercial BUILDING
EPERMITFEE Elect Permit Issuance ELECTRICAL
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Rmdl Sings, Marquee ELECTRICAL
BUSLIC Business License BUILDING
i
f
CITY OF CUPERTINO
jJFEE ESTIMATOR-BUILDING DIVISION
TAPN:
DRESS: 19676 stvns. crk. blvd. DATE: 0 5/2 012 01 1 REVIEWED BY: bobs.
BP#: 'VALUATION: 1$3,000
*PERMIT TYPE: Building Permit
PRIMARY PENTAMATION 1 CEAP5
USE: Sign PERMIT TYPE:
WORK
SCOPE
SIGN TYPE FEE ID QTY SIGN FEE
Wall Sign,Electric 1SIGNWELEC 1 $253
TOTALS: $253.00
Uec/t'h&ail Chc,ck t'bmd,. Yloo t het k #Branch Circuits 1 $42.00
ia<='r. ,=haxrb' Pcrm?!P,"' IESIGN Elec.Permit Fee: IEPERMIT
�r<�r '�k.;t. r`1tsp fuhar°f°Irr,,,777<<,;� OtherElec.Insp. 0.0 $42.00
tJeRr�t. hl'y_ i ce: Phrmh. f•r,p' Tire: Oc(, ht.,p, f�:<�:
NOTE: These ees are based on the prellininary information available and are only an estimate. Contact the De t or addn'1 info.
FEE ITEMS (Fee Resohdion 09-05I E . 7/I/10� FEE QTY/FEE MISC ITEMS
Plan C'hech-Fee:
Suppl.PC Fee: E) Reg. 0 OT 0.0 his $0.00
PltF�rzh,/itrch.lh(r�r:Plon
Permit Fee: $253.00
Suppl. Insp. Feer Reg. 0 OTJ 0.0 hrs $0.00
PME Unit Fee: $42.00
PME Permit Fee: $42.00
C`onsiruclion lcta
Sign Master Plan: Q Yes (E) No $0.00
Work Without Permit? 0 Yes G) No $0.00
F'lcit?,'177t,5 F�'cs: ',
Travel Documentation Fee: ITRA VDOC $42.00
Strong Motion Fee: IBSEISMICO $0.63 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $380.63 $0.00 ` TOTAL FEE: $380.63
Revised: 03/01/2011
I
• FACE LIT with WIREWAY •
I
Frontage=17 ft
I
k
Wood 5"aluminum Return(0.04")
Beam
To Primary - #]0 x 1/2"Tapping Screw
Power Source--�
1_
J-Box Trim Cap
Lock-able
Disconnect Switch = �—Act ylic Face
Flex Conduits _, r LED Module
Metal Wire Way
Power Supply
)/
�3 '�t �f (100-240Vac) _
6
�.,..�.� � �1/4"Drain Holes
t, ao1 #10 x 2"screw
k
•
Sign is U.L. Listed.
142.8,> Area Sign ea" — 16.5 sq ft' 1. Sign Type:Front lit channel letter
2. Letter Face:3/16"acrylic;color:red 2793
3. Letter Return:0.04"dark bronze
16.2» 4. Trim cap:3/4"white
1hC < < � r c
4. Illumination TY
.
5.Other: CUICURD of
REQUIREMENT: Electrical Power(J-Boa)MUST be within 6 feet from sign. Project's Location: 19676 Stevens Creek Blvd, Cupertino, CA.95014
NYNG
This design and drawing submitted for your review and approval is the exclusive property of Phoenix Signs. Proof Date:OS/12/2011 HENRY
` DEjvr
It may NOT be reproduced,copied,exhibited or utilized for any purpose,in whole,by any individual,or sales Person:
V,_.� entity,inside or outside without written consent of Phoenix Signs or purchase,in full,the rights to thereof. Client:Felly Quach-Chiropractor PHOENIX SIGNS
rCI u.,r a suras NYanruFACTURING SOLUTIONS phoenix Signs is NOT responsible for errors in spelling,grammar,punctuation and/or numerical. It is the
446 Queens Lane,San Jose,CA 95112 responsibility of the client to verify all information prior to proceeding with order. Failure to do so may result Costorner's Approval:
Ph:408.573.9300 Fax:408.573.9301 in additional fees. Notice: Once the design is approved,any other changes will be considered a change of Signature Print Name
email pxsigns tr yalmo.com order,and,therefore,pricing will change.
web:Nvww.phoenixsignsusa.coin Landlord's Approval:
Lic#:C-45 924806 All proofs must be signed,dated&sent back. All orders are on hold unfit receipt ofproof with signature. Signature Print Name Date
i
Certificate of Compliance (Sign Lighting) (Page 1 of 4) SLTG-1C
Project Name:
CHIROPRACTOR Date: 5/16/11
Project Address:
19770 STEVENS CREEK BLVD, CUPERTINO, CA 95014
Location of Sign M Outdoor Signs ❑Indoor Signs
Phase of Sign Construction ❑New Signs ❑ Sign Alterations
-Type of Lighting Control ❑New Lighting Controls ❑Replaced Lighting Controls ❑Not Installing Lighting Controls
This Certificate of Compliance includes the following components(check all that apply)
❑Mandatory Measures(Lighting Controls) ®Maximum Allowed Lighting Power ❑ Specific Lighting Sources
1. Certificate of Compliance Declaration Statement(this may be a Clo,C45 or other eligible person)
I certify under penalty of perjury,under the laws of the State of California,the information provided on this form is true and
correct.
I am eligible under Division 3 of the California Business and Professions Code to accept responsibility for the lighting design.
This Certificate of Compliance identifies the lighting features and performance specifications required for compliance with
Title 24,Parts 1 and 6 of the California Code of Regulations.
The design features represented on this Certificate of Compliance are consistent with the information provided to document
this design on the other applicable compliance forms,worksheets,calculations,plans and specifications submitted to the
enforcement agency for approval with this building permit application.
Name Signature // �-P.4� r_o-P aeM 59.,
HUNG TRAN �°Ii�291,�_
W1.:2011 A42012 65'66-07VO'
Company: a Phone
PHOENIX SIGNS 408-573-9300
Address: , License number(may be contractor's lie#)
446 QUEENS LANE 924806, C-45
c'
City/State/Zip: Date
SAN JOSE, CA 95112 `WXX r� 5/16/11
2. Installation Certificate(to be signed by responsible r h er installation)
Permit number Checked by/Date
(Enforcement Agency Use (Enforcement Agency Use
Installation Declaration statement
I certify under penalty of perjury,under the laws of the State of California,the information provided on this form is true and
correct.
I am eligible under Division 3 of the Business and Professions Code to accept responsibility for construction,or an authorized
representative of the person responsible for construction.
I certify that the installed features,materials,components,or manufactured devices identified on this certificate conforms to all
applicable codes and regulations,and the installation is consistent with the plans and specifications approved by the
enforcement agency.
I certify that the requirements detailed on this Certificate of Compliance have been met.
I will ensure that a completed,signed copy of this Installation Certificate 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 signed copy of this Installation Certificate is required to be included with the documentation the builder provides to the
building owner at occupancy.
Company Name:
PHOENIX SIGNS
Responsible Personi ,: SigKay s 1= I M f&h n
Person's.Name: Responsible Person's Signature: n UN:m H� Tr-c=US.o-PhwN
HUNG TRAN Dx e:20„P�9 i2S658-0
License number(may be contractor's,lie#) Date Signed: Position With Company:
924806, C2,45 5/16/11 MANAGER
2008 Nonresidential Compliance Forms October 2010
1
I
I
Certificate of Com fiance (Sign Lighting) (Page 2 of 4) SLTG-1C
Project Name: Date:
CHIROPRACTOR 5/16/11
3.Mandatory Sign Lighting Controls 1
NOTES:
1. The same responsible person may install both the sign lighting power and the sign lighting controls, or a different responsible
person may install the sign lighting controls than the responsible person installing the sign lighting power.
2. The Mandatory Measures (sign lighting controls) are required for compliance with the sign lighting Standards, If the person
responsible for installing the sign lighting power is not also responsible for the sign lighting controls, then the owner of the
sign,general contractor, or architect shall be responsible to have the sign lighting controls installed.
3. If more than one person has responsibility for compliance, each responsible person shall prepare and sign a Certificate of
Compliance and an Installation Certificate applicable to the portion of construction for which they are responsible;
alternatively, the person with chief responsibility for construction shall prepare and sign the Certificate of Compliance
Declaration Statement or the entire construction.
3a. Statements of Responsibility: Any person signing the Certificate of Compliance Declaration Statement on page 1 of
4 on this SLTG-IC shall complete Part 3a.Check Yes or No for all of the following statements:
1 I have responsibility for installing the sign lighting controls
®Yes,complete parts 3a and 3b of this form ❑No,complete part 3a of this form
2 There are no existing sign lighting controls and I will be installing compliant sign lighting controls
El Yes ❑No
3 There are no existing sign lighting controls and someone else will be responsible to install compliant sign lighting controls
❑Yes ®No
There are existing sign lighting controls that do not comply with the applicable provision of§119 and§133 and I will be
4 installing compliant sign lighting controls
El Yes ❑No
There are existing sign lighting controls that do not comply with the applicable provision of§119 and§133 and someone else
5 will be responsible to install compliant sign lighting controls
❑Yes R2 No
3b. Mandatory Sign Lighting Controls
If the person signing the Certificate of Compliance Declaration Statement on page 1 of 4 of this SLTG-1 C is responsible for
-complying with the sign lighting control requirements,that person shall answer all of the following questions:
If there are construction documents,indicate where on the building plans the
mandatory measures(sign lighting control)note block can be located:
1 §133(a)1.All indoor sign lighting is controlled with an automatic time switch control that complies with the Y N NA
applicable requirements of§119. ❑ ® ❑
§133(a)1 and 2. All outdoor sign lighting is controlled with an automatic time switch control plus a photo Y N NA
2 control,or an outdoor astronomical time switch,that comply with the applicable requirements of§119. ® 1 ❑ ❑
Exception to§133(a)2. Outdoor signs in tunnels or large covered areas that require illumination during Y NA
daylight hours. ❑
§133(a)3. All outdoor signs are controlled with a dimmer that provides the ability to automatically reduce Y N NA
sign power by a minimum of 65 percent during nighttime hours. ❑ ❑
Exception 1 to§133(a)3. Si ns illuminated for less than one hour per da during daylight hours. Y NA
P g p Y g ❑
3 Exception 2 to§133(a)3. Outdoor signs in tunnels or large covered areas that require illumination during Y NA
daylight hours. ❑
Exception 3 to§133(a)3.Only metal halide,high pressure sodium,cold cathode,or neon lamps used for Y NA
illuminating signs or parts of signs. ❑ El
§133(a)4. An Electronic Message Center(EMC)having a new connected lighting power load greater than Y N N/A
15 kW has a control installed capable of reducing the lighting power by a minimum of 30 percent when ❑ ❑
4 receiving a demand response signal that is sent out by the local utility.
Exception to§133(a)4.EMC required by a health or life safety statue,ordinance,or regulation,including Y NA
but not limited to exit signs and traffic signs. ❑
Field Inspector Notes:
i
2008 Nonresidential Compliance Forms October 2010
._...............
i
Certificate of Com fiance (Sign Lighting) (Page 3 of 4) SLTG-IC
Project Name: Date:
CHIROPRACTOR 5/16/11
4. Maximum Allowed Lichtinc Power Method of Compliance
Certificate of Compliance and Field Inspection Energy Checklist
Complete this part if there are signs using the maximum allowed lighting power method of compliance.(Complete part 5
of this Certificate of Compliance if there are signs using the S ecific lighting sources method of com liance)
A B C D E I F G H I J
A Allowed Watts Design Complies?
Watts Y/N
4°
0
1:4 U - VI
q Field
o N3 A Y Inspector
11 0 11
Check that
t j Sign
° E° Complies
Description ✓
Al FRONT OF THE STORE ❑ 17 I 12 204 60 Y ❑
❑ ❑ '
❑ ❑
A Symbol or code used on the plans(when plans are required)and other documents.
B A narrative description of the sign,or location of sign on the building;and the location of sign on construction documents.
OPTIONAL-Check this box only if this sign has a permanent,pre-printed,factory-installed,ENERGY VERIFIED label,confirming that
the sign complies with the Section 148 of the California 2008 Title 24,Part 6 Standards,using the Maximum Allowed Lighting Power
method of compliance. The only labels that will be recognized for this purpose are ENERGY VERIFIED Certification Marks authorized
C by Underwriters Laboratories(UL)or other Product Certification Body accredited to ISO/IEC Guide 65 by the American National
Standards Institute in accordance with ISO/IEC 17011.Surveillance by the Accredited Certification Body shall be an ongoing annual
inspection program carried out by a Type A Inspection body in accordance with ISO/IEC 17020. For signs with such an ENERGY
VERIFIED label,columns`D'through`I'are not required to be filled out.Note:Using an ENERGY VERIFIED label is an optional
method to validate compliance.An ENERGY VERIFIED label is not needed for compliance.
D The sign area in square feet.
E List"I"if the sign is internally illuminated. List`B"if the sign is externally illuminated.
F Allowed watts per square foot. Enter 12 if the sign is listed as"I"in column E.Enter 2.3 if sign is listed as`B"in column E.
G Multiply the square footage in column D times the allowed Lighting Power Density(LPD=watts)in column F.
H I Show the total installed watts in the sign,as determined according to the applicable provisions of§130(d ore .
I Enter Y if the number in column H is less than orequal to the number in column G. Otherwise,the sign does not comply.
J This page doubles as a field inspection checklist.
Field Inspector Notes:
i
2008 Nonresidential Compliance Forms October 2010
i
j
Certificate of Compliance (Sign Li htin ) (Pa e 4 of 4) SLTG-1C
Project Name: Date:
CHIROPRACTOR 5/16/11
5. Specific Lighting Source Method of Compliance
Certificate of Compliance and Field Inspection Energy Checklist
Complete this part if there are signs using the Specific lighting source method of compliance. (Complete part 4 of this
Certificate of Compliance if there are signs using the maximum allowed lighting power method of compliance)
A B C D E
OPTIONAL Field
ENERGY Specific light source used for
Symbol VERIFIED compliance Inspector
Check that
or Description label Shall include only lighting
Code (see instructions technologies listed below Sign
below) List all that apply Complies
✓ ✓
LED LIGHTING ❑ D8 ❑
A Symbol or code used on the plans when plans are required)and other documents.
B A narrative description of the sign,or location of sign on the building;and the location of sign on construction documents
C OPTIONAL-Check this box only if this sign has a permanent,pre-printed,factory-installed ENERGY VERIFIED label,confirming that
this sign complies with the Section 148 of the California 2008 Title 24,Part 6 Standards,using the Specific Lighting Source Method of
Compliance. The only labels that will be recognized for this purpose are ENERGY VERIFIED Certification Marks authorized by
Underwriters Laboratories(UL)or other Product Certification Body accredited to ISO/IEC Guide 65 by the American National Standards
Institute in accordance with ISO/IEC 17011.Surveillance by the Accredited Certification Body shall be an ongoing annual inspection
program carried out by a Type A Inspection body in accordance with ISO/IEC 17020.For signs with such an ENERGY VERIFIED label,
column`D'is not required to be filled out.Note:Using an ENERGY VERIFIED label is an optional method to validate compliance.An
ENERGY VERIFIED label is not needed for compliance.
Specific Light Source Compliance Method. The sign(s)identified above use only the following lighting technologies:
List all applicable numbers 1 through 10 that apply in column D above for each row.
I High pressure sodium lamps
2 Pulse start or ceramic metal halide lamps served by a ballast with >88%efficiency
3 Pulse start metal halide lamps that are 5 320 watts,are not 250 watt or 175 watt lamps,and are served by a ballast
with>80%efficiency
4 Neon or cold cathode lamps with transformer or power supply efficiency> 75%with rated out
put current<50 mA
D 5 Neon or cold cathode lamps with transformer or ower supply efficiency>68%with rated output current>50 mA
6 Fluorescent lamps with a minimum color rendering index(CRI)of 80
(Note:when using electronic ballasts for compliance,lamps with a CRI<80 may be used
7 Light emitting diodes(LEDs)with a power supply with> 80%efficiency
Single voltage LED external power supplies designed to convert 120 volt AC input into lower voltage DC or AC
8 output,having a nameplate output power less than or equal to 250 watts,and certified to the Energy Commission as
complying with the applicable requirements of the Appliance Efficiency Regulations(Title 20)
9 Compact fluorescent lamps that do not contain a medium screw base sockets(E24/E26)
10 1 Electronic ballasts with a fundamental output frequency>20 kHz
E This page doubles as a field inspection checklist.
Field Inspector Notes:
I
2008 Nonresidential Compliance Forms October 2010
A110 I W 4-11,A212 A"AIN
From: Phoenix Signs
446 Queens Lane
San Jose, CA. 95112
To whom it may concern,
My name is Hung Tran, and I am the contractor with the license#: C-45 924806, and
Worker's Comp #: 76WEGJX4500. I would like to authorize Do Tran, my employee,to
obtain the permit and/or the business license on my behalf.
I
Regards,
Hung Tran
i