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15050162.C9 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10612 S DE ANZA BLVD CONTR__CTR: PERMIT NO: 15050162 � 3e JLORU A\ in OWNER'S NAME: BYER PROPERTIES LP t /+G E. DATE ISSUED: 07/23/2015 OWNER'S PHONE: 4085091575 ©(JN LSAI\/ [; PHONE NO )6W LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION-dS'IDMfl6&n COMMERCIAL ARGONAUT - T.I. TO REMOVE DEMISING WALL & � ^ rL License Class Lic.# �(�D(-'7 EXPAND Contractor Date (�� TO NEIGHBORING SUITE, RECONFIGURE AND REMODEL 2,400 S.F. I hereby affirm that I am licens nder the provisions of Chapter 9 (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 Sq. Ft Floor Area: Valuation: $12000 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 APN Number: 36938037.10612 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct. I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save 180 S FROM LAST CALLED INSPE TIO indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the�� V v�C granting of this permit. Additionally, the applicant understands and will comply Issued by: Date: with all non-point so rce r ulations per the Cupertino Municipal Code, Section 9.18. 411-10-1 RE-ROOFS: Signature Date ?1:2311.5 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. ❑ OWNER-BUILDER DECLARATION Signature of Applicant: Date: I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER 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 HAZARDOUS MATERIALS DISCLOSURE construct the project (Sec.7044, Business & Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the declarations: Health & Safety Code, Section 25532(a) should I store or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally, should I use equipment or devices which emit hazardous Compensation, as provided for by Section 3700 of the Labor Code, for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the Cupertino unicipal Code, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the of the work for which this the Health & Safety Code, Section 25 3 and 25534. performance Owner or authorized agent: Date: 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 CONSTRUCTION LENDING AGENCY 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 I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name APPLICANT CERTIFICATION 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 city to enter upon the above mentioned property for inspection purposes. (We) agree to save ARCHITECT'S DECLARATION indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit. Additionally, the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code, Section Licensed Professional 9.18. Signature Date CUPERTINO, ❑ NEW CONSTRUC CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228.- FAX (408) 777-3333 • building(a)cupertino.orq /50 I -ION ❑ ADDITION tgAL.TERATION / TI ❑ REVISION / DEFERRED ORIGINAL PERMIT # PROJECf ADDRESS ' y, APN R ((),61 1 O , `Jii ,6 OWNER NAME ,i PHONE E-MAIL � � •� ��� lJ i F4/ C STREET ADDRESS / STATE, ZIP FAX Loa—E SCO66 CONTACT NAME PHONE E-MAIL sT l STREET ADDRESS 1 _ CITY, STATE, ZIP FAX ❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT . CONTRACTORNAME '7 LICENSEIZUMBER LICENSETYPE BUS. LIC N COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARCHITECT/ENGINEER NAME LICENSE NUMBERBUS. LIC As�U, 74 �� 0� COMPANY NAME Ne E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP _ 71jPHONE DESCRIPTION OF WORK �l a rvL 10 l—1X 7600P Vo IA, a 1 EXISTING USE PROPO ED USE CONSTR TYPE STORIES - 0 USE TYPE OCC. SQ.FT. VALUATION (S) EIOSTG NEW FLOOR- AREA AREA i S -4 DEMO AREA TOTAL NET AREA"? ii.,,,,, ' l % O l Z �'• &` 4 c'_L¢3'� 4 _.y BATHROOM. KITCHEN. OTHER, REMODEL AREA REMODEL AREA REMODEL AREA PORCHAREA DECK AREA TOTALDECK/PORCH AREA GARAGE AREA: DETACH ❑ ATTACH 9 DWELLING UNrrS: IS A SECOND UNIT ❑ YES SECOND STORY []YES BEINGADDED? []NO ADDITION? ❑NO PRE -APPLICATION ❑YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ t CEI DATION: - PLANNING ADPL,- ❑ NO ' PLANNING APPROVAL LEITER EICHLER HONIE? ❑ �" - - - / O I s 6 (� By my signature below, I certify to each of the follov✓ing: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have provided is c947ect. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building cons tion. I authorize representatives of Cupertino to enter the above-ientified property for inspection purposes. Sia ature of Applicant/Agent: Date: Z-51 15 SUPPLEMENTAL INFVRI�I REQUIRED�NcaECxa��rroNI41.17�? Itew SFD or Multifamily dna ellingy fo, demolition permit for ©� of i Co II.rERu' IMP ERNE I DING PLA LRE3TIEFiµ existing building(s). Demolition permit is required for to issuance ofbuilding5, . permit for new buildingMESA 1� ExP$Ess f FLAxI+I ,cT LATvxEy�, 7 MWI ON SR _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure Q 02 STAPB, LKewo��Tcs�� _ form if any Hazardous Materials are being used as part of this project. ,� ter, Copy of Planning Approval Letter or Meeting with Planning to _ prior submittal of Building Permit application. BldgApp_2011.doc revised 06/21/11 Yov 411 h P )v' t 4 -ug WE����,,��--,,�� CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION OCCUPANCY TYPE: ADDRESS: 10612 S DE ANZA BLVD DATE: 05/27/2015 REVIEWED BY: PAUL PC FEE ID APN: 369 38 037 BP#: / f g___ VALUATION: 1$12,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement PRIMARY USE: Commercial Building IBTIPLNCK PENTAMATION PERMIT TYPE: 1 B TA WORK ARGONAUT - T.I. TO RECONFIGURE AND EXPAND EXISTING B OCCUPANCY 2400 SQ FT.). SCOPE OCCUPANCY TYPE: TYPE OF CONSTR. FLR AREA s.f. PC FEES PC FEE ID BP FEES BP FEE ID B (Tenant Improvements) II-B,III-B,IV,V-B 2,400 $2,291.14 IBTIPLNCK $2,131.79 1BTIINSP lilec. Insp. hese: PME Plan Check: $0.00 Permit Fee: $2,131.79 Suppl. Insp. Feer Reg. Q OT 0,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 TOTALS: 2,400 $2,291.14 Construction 7'cry: $2,131.79 '..: 77 MECH,.HOURLY Yes :.; No; PLUMB, HOURLY, .._ Yes No. ELEC,.HOURLI' ®.Yes ;L9eeh. Plan ('heck Phunb. Plan Check Elec. Plan Check ;blech. Pennit Fee: Plumb. Permit Fee: lilac. Permir Fee: t)rhe:r Alech..... Other Plwnb Insn. Other Elec. Insp. ED-L-- A4ech Insp. hese: Phinrb. hap. Fce lilec. Insp. hese: NOTE: This estimate does not include fees due to other Departments (i.e. Planning, rubuc woras, rue, aamrary,3ewer utsrrcct, acauuc n:orr:..i afn 1 Thorn %oc oro hacad nn fho nroliminani infnrmadan availahle and are only an estimate. Contact the Dent for addn'I info. FEE ITEMS (Fee Resolution 11-053 E f 711/13) FEE QTY/FEE MISC ITEMS Plan Check Fee: $2,291.14 Select a Misc Bldg/Structure or Element of a Building Suppl. PC Fee: (E) Reg. 0 OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $2,131.79 Suppl. Insp. Feer Reg. Q OT 0,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction 7'cry: .Adinlnistrative Fee: 0 E) Work Without Permit? 0 Yes No $0.00 Advanced Planning Fee: $0.00 Select a Non -Residential Building or Structure I G 0 A Travel Doc, uinew. ath-)n Fees: Strong Motion Fee: IBSEISMICO $3.36 Select an Administrative Item Bldg Stds Commission .Fee: IBCBSC $1.00 SUBTOTALS:' $4,427.29 $0.00 TOTAL FEE. $4,427.29 Revised: 05/07/2015 Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR / SUBCONTRACTOR LIST JOB ADDRESS: � a Vd PERMIT # so OWNER'S NAME: r e.(' f e- PHONE # GENERAL CONTRAC OR: BUSINESS LICENSE # ADDRESS: l V C: f -q A00, C CITY/ZIPCODE: Ofi *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Signature Please check applicable subcontractors and complete the following information: Date Owner/ontractor Signature Date SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical % -b n r V i S o1 � ✓' Excavation Fencing Flooring / Carpeting i G r S ' f V i C2 -Incr Linoleum / Wood Glass /Glazing e i' �' 0.S` % Go rA Heating 2 Insulation-7� Landscaping Lathing Masonry Painting / Wallpaper h4 cam Q 1 l' 9 9 Paving Plastering 3 `7 Plumbing 1k -m1 b\!o Roofing Septic Tank Sheet Metal Sheet Rock Ua A C,3 (p (p Tile ad H e5 3 b -7-7 Owner/ontractor Signature Date STATE OF, LIFORNIA FENESTRATION WORKSHEET CEC-NRCC-ENV-02-E (Revised 06/14) CALIFC Vt ENERGY COMMISSION CERTIFICATE OF COMPLIANCE NRCC-ENV-02-E Fenestration Worksheet (Page 1 of 3) Pr°iect"ar"e' DE ANZA CENTER TENANT ADDITIONAL SPACE Date Prepared: 5-08-15 A. WINDOWS DETAILS Worksheet §140.3(a)56 and C NOTE: Newly installed fenestration shall have a certified NFRC Label Certificate or use the GEC default tables found in Table 116-A and Table 1168. Site -built fenestration less than 1,000 R2, or more than or equal to1,000 ft2 see Reference Nonresidential Appendix NA6. 1 2 3 4 1 5 1 6 1 7 1 8 1 9 10 1 11 1 12 13 14 Tag/I D Window Type (e.g., Window -1 Area Fenestration C. Enter Larger of A or B 189 ft2 Maximum Standard West Area Overhang LI -Factor SHGC VT C. WINDOW AREA CALCULATION for all other orientations other than West - See §140.3(a)5A in the Energy Standards Dimensions 472 1 ft2 x 0.40 = Calculated Q) -0 W a) o _o o- Q 0) _0 (n 4) o _o o °- ¢ m V) OL a Q) _o Q H V HN (R)SHGC Proposed (R )SHGC Allowed WINDOW 27 0.22 0.36 0.21 0.4 0.41 0.42 B. WEST WINDOW AREA CALCULATION See §140.3(a)5A in the Energy Standards A. Gross West Exterior Wall Area 472 ft2 x 0.40 = 189 ft2 40% of Gross West Facing Exteri II Area; or B. West Display Linear Perimeter 29.5 FT x 6 ft = 177 ft2 West Display Perimeter Area C. Enter Larger of A or B 189 ft2 Maximum Standard West Area D. Enter Proposed West Window Area 0 ft2 1 Proposed West Window Area Note: If the PROPOSED WEST WINDOW AREA is greater than the MAXIMUM STANDARD WEST AREA then the envelope component approach may not be used. C. WINDOW AREA CALCULATION for all other orientations other than West - See §140.3(a)5A in the Energy Standards E. Gross Exterior Wall Area 472 1 ft2 x 0.40 = 189 40% of Gross Exterior Wall Area or F. Linear Display Perimeter 29.5 FT x 6 ft = 177 ft2 Display Perimeter Area G. Enter The Larger of E or F 189 ft2 Maximum Standard Area H. Enter Proposed Window Area 27 ft2 Proposed Window Area Note: If the PROPOSED WINDOW AREA is greater than the MAXIMUM STANDARD AREA then the e. Y lope component approach may A' boll Mj D. SKYLIGHT AREA CALCULATION See §143(a)6A in the Energy Standards ACTUAL GROSS STANDAR 81,41 ROOF AREA ALLOWED A IF Atrium/Skylight Height is _< 55 ft; or ft2 - 0.05 = " '� ft2 B. IF Atrium/Skylight Height is > 55 ft ft2 - 0.10 = ft2 C. Proposed Skylight Area (from plans) ft .�+ D. Skylight SSR %' ` = Proposed Skylight Area Divided by Actual Gross % 1. If the SKYLIGHT SSR % is less than or equal to 5% then choose the appropriate column in Table 140.3-B id C and row in Table 140.3-0. 2. If the SKYLIGHT SSR % is greater than 5% then the Envelope Component Approach may not be used. CA Building Energy Efficiency Standards - 2013 Nonresidential Compliance June 2014 STATE OF CALIFORNIA FENESTRATION WORKSHEET CEC-NRCC-ENV-02-E (Revised 06114) CALIFC ENERGY COMMISSION CERTIFICATE OF COMPLIANCE NRCC-ENV-02-E Fenestration Worksheet (Page 3 of 3) Project Name: DE ANZA CENTER TENANT ADDITIONAL SPACE oai Ptepdfedi 5-08-15 DOCUMENTATION AUTHOR'S DECLARATION STATEMENT 1. I certify that this Certificate of Compliance documentation is accurate and complete. Documentation Author Name: Joel Manzanillo Documentation Author Signature Company: Belden Consulting Engineers Signature Date: 5-08-15 Address: 5860 W Las Positas Blvd Suite 15 CEA/ HERS Certification Identification (if applicable): city/state/zip: Pleasanton CA 94588 Phone: 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. 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. 5. 1 will ensure that a completed signed copy of this Certificate of Compliance shall be 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 completed signed copy of this Certificate of Compliance is required to be included with the documentation the builder provides to the building owner at occupancy. Responsible Designer Name: Responsible Designer Signature: Company: Date Signed: Address: License: City/State/Zip: Phone: CA Building Energy Efficiency Standards - 2013 Nonresidential Compliance June 2014 STATE OF CALIFORNIA ENVELOPE COMPONENT APPROACH CEC-NRCC-ENV-01-E (Revised 06114) CALIFORNIA ENERGY COMMISSION CERTIFICATE OF COMPLIANCE NRCC-ENV-01-E Envelope Component Approach (Page 1 of 4) Project Name: DE ANZA CENTER TENANT ADDITIONAL SPACE °aye"'eo"�: 5-08-15 A. GENERAL INFORMATION 1 Project location: 10612 SOUTH DE ANZA BLVD 6 Compliance Method: PRESCRIPTIVE Z Component ❑ Unconditioned (file Affidavit) 2 CA City and Zip Code: Cupertino, CA 95014 7 Building Front Orientation (deg or cardinal): WEST 3 Climate Zone: 4 8 Permitted Scope of Work I ❑ New Construction ❑ Addition M Alteration 4 Total Conditioned Floor 2521 9 Area: Building Type(s) ® Nonresidential ❑ High -Rise Residential ❑ Hotel/Motel Guest Room 5 ❑ Schools (Public School) ❑ Relocatable Public School Bldg. ❑ Conditioned Spaces ❑ Unconditioned Spaces ❑ Skylight Area for Large Enclosed Space > 5000 ft2 (If checked include the NRCC-ENV-04-E with submittal) B. ENVELOPE DETAILS — Framed 1 2 3 4 5 6 7 8 9 11 Tag/ID Assembly Type Frame Material Frame Depth Frame Spacing Appendix JA4 Reference Cavity R -value Continuous Insulation R -value Proposed U -Factor Required U -Fa r Fr Tables, B, Comments C. ENVELOPE DETAILS — Non -framed 1 2 3 4 5 6 7 8 9 10 Tag/ID Assembly Type Assembly Materials Thickness (inches) Interior or Core Insulation R -value Continuous Insulation R -value Appendix JA4 Reference Proposed U -Factor Required U -Factor from Tables, B, C, D Comments D. ENVELOPE DETAILS —Mass 1 2 3 4 5 6 7 8 9 10 11 Tag/ID Mass Type Density (Ib/ft" Mass Thickness (inches) Furring Strip Thickness (inches) Interior Insulation R -value Exterior Insulation R -value Appendix JA4 Reference Proposed Insulation U -factor Required U-Factorfrom C% Tables, B, C, D Commen CA Building Energy Efficiency Standards - 2013 Nonresidential Compliance �X June 2014 STATE OF CALIFORNIA ENVELOPE COMPONENT APPROACH CEC-NRCC-ENV-01-E (Revised 06114) CALIFORNIA ENERGY COMMISSION CERTIFICATE OF COMPLIANCE NRCC-ENV-01-E Envelope Component Approach (Page 2 of 4) Project Name. I Date Prepared' E. ROOFING PRODUCTS (COOL ROOF) 1 2 3 4 S 6 7 8 9 10 11 Mass Roof 251b ft2 or greater Roof Pitch CRRC Product ID Number Product Type Proposed Minimum Required Comments Aged Solar Reflectance Thermal Emittance SRI' (Optional) Aged Solar Reflectance Thermal Emittance SRI (optional) ❑ ❑1 ❑ ❑' ❑ ❑1 ❑ An aged solar reflectance less than 0.63 is allowed provided the maximum roof / ceiling U -factor in TABLE 140.3 is not exceeded ❑ High-rise residential buildings and Hotels and Motels with low -sloped roofs in Climate Zones 1 through 8, 12 and 16 are exempted from aged Solar Reflectance and emittance requirements. ❑ High-rise residential buildings and Hotels and Motels with steep -sloped roofs in Climate Zones 1 and 16 are exempt from aged Solar Reflectance and emittance requirements. ❑ The roof area covered by building integrated photovoltaic panels and building integrated solar thermal panels are exempt from aged Solar Reflectance and emittance requirements To apply Liquid Field Applied Coatings, the coating must be applied across the entire roof surface and meet the dry mil thickness or coverage recommended by the coatings manufacturer and meet minimum performance requirements listed in §110.8(i)4. Select the applicable coating: ❑ Aluminum -Pigmented Asphalt Roof Coating ❑ Cement -Based Roof Coating ❑ Other NOTES: 1. Check the box if the aged Solar reflectance was not available in the Cool Roof Rating Council's Rated Product Directory, Then use the equation in Section 110.8(i)2 where the Initial Reflectance value from the some directory and use the equation (0.2+B(pj„ jt;ai —0.2) to obtain a calculated aged value. Where pis the Initial Solar Reflectance and B is either set to 0.65 for Field -Applied Coatings or it is set to 0. 70for all other roofing products other than Field -Applied Coating. 2. Calculate the SRI Value by using the SRI -Worksheet at (TBD) and enter the resulting value in the SRI Column above and attach a copy for the SRI -Worksheet NRCC-ENV-03-E to the to this form. F. Air Barrier 1 2 3 4 5 Tag/ID Air Barrier Material Type Air Barrier Assembly Type Whole Building Air Leakage Testing Comments CA Building Energy Efficiency Standards - 2013 Nonresidential Compliance lune 2014 STATE OF CALIFORNIA ENVELOPE COMPONENT APPROACH CEC•NRCC-ENV-01-E Revised 06114 CALIFORNIA ENERGY COMMISSION CERTIFICATE OF COMPLIANCE NRCC-ENV-01-E Envelope Component Approach (Page 3 of 4) P,.j-; Namz. Dale PrepareJ: G. FENESTRATION PROPOSED AREAS AND EFFICIENCIES 1 2 3 4 5 6 7 8 9 10 11 12 Tag/ID Fenestration Type Area Orientation N, S, W, E or Roof # of Panes Max LI -Factor Overhang Max (R)SHGC Min VT Label Conditions Status Comments 103A WINDOW 27 E 3 0.22 0.21 0.41 NFRC NEW H. ENVELOPE MANDATORY MEASURES Indicate location on building plans of Mandatory Envelope Measures Note Block: INSTRUCTIONS TO APPLICANT ENVELOPE COMPLIANCE & WORKSHEETS (check box if worksheet are included) For detailed instructions on the use of this and al! Energy Efficiency Standards compliance forms, please refer to the Nonresidential Compliance Manual. ® NRCC-ENV-01-E Certificate of Compliance. Required on plans for all submittals. 13 NRCC-ENV-04-E Use when minimum skylight requirements for large enclosed spaces are required in climate zones 2 through 15. Optional on plans. CA Building Energy Efficiency Standards - 2013 Nonresidential Compliance June 2014 STATE OF CALIFORNIA ENVELOPE COMPONENT APPROACH CEC-NRCC-ENV-01-E (Revised 06/14) CALIFORNIA ENERGY COMMISSION CERTIFICATE OF COMPLIANCE NRCC-ENV-01-E Envelope Component Approach (Page 4 of 4) Project Name: Date Prepared: DOCUMENTATION AUTHOR'S DECLARATION STATEMENT 1. 1 certify that this Certificate of Compliance documentation is accurate and complete. Documentation Author Name: Joel Manzanillo Documentation Author Signature: Company: Belden Consulting Engineers Signature Date: 55_08-15 Address: 5860 W Las Positas Blvd Suite 15 CEA/ HERS Certification Identification (if applicable): City/state/zip Pleasanton CA 94588 Phone: 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. 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. 1 will ensure that a completed signed copy of this Certificate of Compliance shall be 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 completed signed copy of this Certificate of Compliance is required to be included with the documentation the builder provides to the building owner at occupancy. Responsible Designer Name: Responsible Designer Signature: Company: Dale Signed: Address: License: City/State/Zip: Phone: CA Building Energy Efficiency Standards - 2013 Nonresidential Compliance June 2014 lo- CITY MECHANICAL, Inc. CMI JOB NO. 67730 PROJECT De Anza Center - Argonaut Showroom SYSTEM OUTLET MANUFACTURER TEST APPARATUS Page i of AIR OUTLET TEST REPORT York Package Unit Alnor TEST DATE: 2/1/2016 READINGS BY: Mike Vosberg STATE OF CALIFORNIA PROJECT SUMMARY CALIFORNIA ENERGY COMMISSION MATION , Project Name: De Anza Center - Tenant Additional Space Enforcement Agency: The City of Cupertino Building Department Permit Number: 15050162 Project Address: 10612 South De Anza Blvd. City: Cupertino Zip Code: 95014 Project Number: 1510-00017 Acceptance Test Employer: Stephen Cusella - ETT -1505-00005 Acceptance Test Technician: Christian Cusella - ATT -1503-00023 NRCA-LTI-02-A NRCA-LTI-03-A NRCA-LTI-04-A NRCA-LTO-02-A umNational Lighting Contractors Association of America a # FORM BUILDING FLOOR ROOM 1 Occupancy Sensor Acceptance Test 1 1 Showroom 2 Automatic Daylight Continuous Dimming Lightmeter 1 1 Showroom 3 Occupancy Sensor Acceptance Test 1 1 Office 4 Occupancy Sensor Acceptance Test 1 1 Private Office 5 Occupancy Sensor Acceptance Test 1 1 Bathroom -Sample untested areas are attached in different document. S,'ATE OF CALIFORNIA AU"rUMATIC DAYLIGHTING CONTROL ACCEPTANCE DOCUMENT CEC-NBCA-LTI-03-A (Revised 06/14) CALIFORNIA ENERGY COMMISSION KA i National Lighting Contractors - ASsnriation of Amprira PROJECT NUMBER: 1510-00017 CERTIFICATE OF ACCEPTANCE - NRCA-LTI-03-A Automatic Daylight Continuous Dimming Lightmeter Project Name: De Anza Center - Tenant Additional Space Enforcement Agency: The City of Cupertino Permit Number: 15050162 Building Department Project Address: 10612 South De Anza Blvd. City: Cupertino Zip Code: 95014 Building: 1 Floor: 1 Room: Showroom Note: Submit one Certificate of Acceptance for each system that must demonstrate compliance. Enforcement Agency Use: Checked by/Date: A: Construction Inspection NA -7.6.1.1 1.- Drawing of Daylit Zone(s) must be shown on plans or attached to this form, Select one or both of the following: Shown on plans page Vs E3 Daylit zones(s) drawn in on as -built plans (attached) page Vs Applicable Control System 2: System Information Zone Type: Skylit (Sky), Primary Sidelit (PS), or Secondary Sidelit (SS) Sky PS SS Control Type: Continuous Dimming with more that 10 light levels (C), Stepped Dimming (SD), Switching (SW) C C Design Footcandle: (enter number or Unknown) unknown fc unknown fc 3.- Sensor and Controls Control Loop Type:Open Loop (OL), Closed Loop (CL) CL CL Sensor Location: Outside (0), Inside Skylight (IS), Near Windows facing out (NW), In Controlled Zone (CZ) CZ CZ Sensor Location is Appropriate to Control Type: (Y/N) If control loop type is Open Loop (OL): Enter yes (Y) if location = Outside (0), Inside Skylight (IS), or Near Windows facing out (NW); otherwise, enter no (N). if control loop type is Closed Loop (CL): Enter yes (y) if location = In Controlled Zone (CZ); otherwise, enter no (N). Yes Yes Control Adjustments are in Appropriate Location (Y/N): Yes, If Readily Accessible or Yes if in Ceiling <= 11 ft, No for all other. Yes Yes 4: Has documentation been provided by the installer. Installation Manuals and Calibration Instructions Provided to Building Owner: (Y/N) Yes Yes Location of Lights Sensor on Plans: (Y/N) Yes Yes Location of Light Sensor on Plans: (Page Number) E3 E3 5.- Seperate Controls of Luminaires in Daylit Zones: Are Luminaires controlled by automatic daylighting controls only in daylit zones (Y/N) Yes Yes Seperately circuited for daylit zones by windows and daylit zones under skylights: (Y/N) Yes Yes 6.- Daylighting control device certification Daylighting control has been certified in accordance with Section 110.9: (Y/N) Yes Yes Construction Inspection Pass/Fail. If all responses on this Construction Inspection are complete and all YES/NO questions have a Yes (Y) response, the tests Pass; if any responses on this page are incomipete OR there are any No (N) responses, the test Fails Yes Yes If sampling method is used in accordance with NA7.6.1.2, attach a page with names of other controls in sample (only for buildings with > 5 daylight control systems, sample group glazing same orientation) Page 1 o/ 4 B, Functional Performance Testing - Continuous Dimming Systems NA -7.6.1.2.1 - Power estimation using light meter measurement System Information a Control Loop Type. Open Loop or Closed Loop? (O or C) C C b Indicate if Mandatory control- M ( required for skylit zone or primary sidelit zone with installed general lighting power >120 W); for Control Credit- CC; or Voluntary not For credit - V (M,CC,V) M V c If automatic daylighting controls are mandatory, are all general lighting luminaires in daylight zones controlled by automatic daylight controls? (Y/N) Yes Yes d Documented general lighting desing footcandle. If design foodcandles not documented leave blank.(Enter fc) e Power estimation method. (see line r) Default ratio of power to light (Dfc), cut -sheet ratio of power to light (CSfc) If CSfc-attach cut -sheet. Enter Dfc or CSfc CSfc CSfc Step 1: Identify Reference Location (location where minimum daylight illuminance is measured in zone served by the controlled lighting.) f I Method Used: Illuminance or Distance (I or D) D D Override daylight control system and drive electric lights to full light output for highest light level fc: gHighest light level fc - enter measured controlled electric lighting footcandles (fc) 62.6 fc 61.3 fc h I Indicate whether this is Full Output (FO), or Task Tuned (Lumen Maintenance)(TT) FO FO Step 2: No Daylight Test i Method Used: Night time manual measurement (Night), Night Time Illuminance Logging (Log), Cover Fenestration (CF), Cover Open Loop Photosensor (COLP) Night Night j Reference Illuminance (foot-candles) measured at Reference Location (Illuminance of general lighting at the reference location) 58.9 fc 58.9 fc k Enter Y if either of the following statements are true: [Reference Illiminance (line j)] / [Full Output fc (line g)] > 70%? or [Reference Illiminance (line j)] / [design footcandles (line d)] > 80%? (Y/N) Yes Yes Step 3. Full Daylight Test conducted when daylight > reference illuminance (line j) I IDaylight illuminance (light level with electric lighting turned off) measured at Reference Location (fc) 67.7 fc 68.6 fc m Daylight illuminance (line 1) greater than Reference Illuminance (line j)? (Y/N) Yes Yes n Fraction controlled wattage turned off. Enter % 39.14% 40.46% o Fraction of controlled wattage dimmed [1 -(line n)] 60-86% 59.54% Fill out lines p through s only if fraction of controlled wattage turned off (line n) < 100% p Total (daylight + electric light) illuminance measured at the Reference Location (fc) 100 fc 100 fc q Electric lighting illuminance at the Reference Location (fc)[(line p) - (line 1)] 32.30 fc 31.40 fc r Electric lighting illuminance (line q) divided by Highest Light Level fc (line g). Enter % 46.77% 47.54% s Dimmed luminaire fraction of rated power. Attach manufacturer's cut -sheet or use default graph of rated power to light output on bottom of this form. Label applicable control system on cut -sheet or graph. Enter fraction of rated power in %. 54% 56% t System Power Reduction = [1 - (line o) * (line s)] 67.14% 66.16% u Is System Power Reduction (line t) > 65% when line h = FO, or > 56% when line h = TT (Y/N) Yes Yes v With uncontrolled lights also on, no lamps dimmed outside of daylit zone by control (Y/N) Yes Yes w Dimmed lamps have stable output, no perceptible flicker (Y/N) Yes Yes Step 4 : Partial Daylight Test conducted when daylight between 60% and 95% of (line j) x Daylight ilium inance(lightest level without electric light) measured at Reference Location (fc) 52 fc 52 fc y Daylight illuminance divided by the Reference illuminance = (line x) / (line j). Enter %. 88.29% 88.29% z Is Ratio of Daylight illuminance to Ref. illuminance (line y) between 60% and 95% (Y/N) Yes Yes as Total (daylight + electric light) illuminance measured at the Reference Location (fc) 62 fc 62 fc bb Total illuminance divided by the Reference Illuminance = (line aa) /(line j), Enter % 105.26% 105.26% cc Is Ratio of Total illum. to Reference illuminance (line bb) between 100% and 150%? (Y/N) Yes Yes Page 2 of 4 W. PASS / FAIL Evaluation (check one): LI PASS: All applicable Construction Inspection responses are complete and all applicable Functional Performance Testing Requirements responses are positive (Y - yes) (applicable questions = c, k, m, u, v, w, z, cc) D FAIL: Any applicable Construction Inspection responses are incomplete OR there is one or more negative (N - no) responses in any applicable Functional Performance Testing Requirements section (applicable questions = c, k, m, u, v, w, z, cc). System does not pass and is NOT eligible for Certificate of Occupancy according to Section 10-103(a)3B. Fix problem(s) and retest until the system(s) passes all portions of this test before retesting and resubmitting NRCA-LTI-03-A with PASSED test to the enforcement agency. Describe below the failure mode and corrective action needed. Page 3 of 4 i ATE OF CALIFORNIA AUTOMATIC DAYLIGHTING CONTROL ACCEPTANCE DOCUMENT CEC-NRCA-LTI-03-A (Revised 06/14) CALIFORNIA ENERGY COMMISSION n' National Lighting Contractors Association of America CERTIFICATE OF ACCEPTANCE - NRCA-LTI-03-A Automatic Daylighting Control Acceptance Document Project Name:: De Anza Center - Tenant Additional Space Enforcement Agency: The City of Cupertino Building Department Permit Number: 15050162 Project Address: 10612 South De Anza Blvd. City: Cupertino Zip Code: 95014 DOCUMENTATION AUTHOR'S DECLARATION STATEMENT I certify that this Certificate of Acceptance documentation is accurate and complete. Documentation Author Name: Documentation Author Signature: Christian Cusella Documentation Author Company Name: Date Signed: February 4, 2016 General Lighting Service Address: 975 Chestnut ave. CEA/HERS/ATT Certification Identification (If applicable): ATT -1503-00023 City/State/Zip: San Jose CA, 95110 Phone: 000-000-0000 FIELD TECHNICIAN'S DECLARED 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 Acceptance is true and correct. 2. 1 am the person who performed the acceptance verification reported on this Certificate of Acceptance (Field Technician). 3. The construction or installation identified on this Certificate of Acceptance complies with the appicable acceptance requirements indicated in the plans and specifications approved by the enforcement agency, and conforms to the applicable acceptance requirements and procedures specified in Reference Nonresidential Appendix NA7. 4. 1 have confirmed that the Certificate(s) of installation for the construction or installation identified on this Certificate of Acceptance has been completed and signed by the responsible builder/installer and has been posted or made available with the building permit(s) issued for the building. Field Technician Name: Field Technician Signature ^� Christian Cusella Field Technician Company Name: General Position with Company (Title): Accepta a Test Te hnicia Lighting Service Address: 975 Chestnut ave. ATT Certification Identification (If applicable): ATT -1503-00023 City/State/Zip: San Jose CA, 95110 Phone: 408-761-7967 Date Signed: February 4, 2016 RESPONSIBLE PERSON'S DECLARATION STATEMENT I certify the following under penalty of perjury under the laws of the State of California: 1. I am the Field Technician, or Field Technician is acting on my behalf as my employee or my agent and I have reviewed the information provided on this Certificate of Acceptance. 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 Acceptance and attest to the declarations in this statement (responsible acceptance person). 3. The information provided on this Certificate of Acceptance subtantiates that the construction or installation identified on this Certificate of Acceptance complies with the acceptance requirements indicated in the plans and specifications approved by the enforcement agency, and conforms to the applicable acceptance requirements and procedures specified in Reference Nonresidential Appendix NA7. 4. 1 have confirmed that the Certificate(s) of Installation for the construction or installation identified on this Certificate of Acceptance has been completed and is posted or made available witht the building permit(s) issued for the building. 5. 1 will ensure that a completed, signed copy of this Certificate of Acceptance shall be posted, or made available witht 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 Certificate of Acceptance is required to be included with the documentation the builder provides to the building owner at occupancy. Responsible Acceptance Person Name: Responsible Acceptance Person Signatu e: Stephen Cusella Responsible Acceptance Person Company Position with Company (Title): Acceptance Test Employer Name: General Lighting Service Address: 975 Chestnut ave. CSLB License: City/State/Zip: San Jose CA, 95110 Phone: 408-298-6670 Date Signed: February 4, 2016 Page 4 of 4 STATE OF CALIFORNIA « AUTOMATIC DAYLIGHTING CONTROL ACCEPTANCE DOCUMENT CEC-NRCA-LTI-03-A (Revised 06/14) CALIFORNIA ENERGY COMMISSION �NLLonn National Lighting Contractors Association of America PROJECT NUMBER: 1510-00017 CERTIFICATE OF ACCEPTANCE - NRCA-LTI-03-A Automatic Daylight Continuous Dimming Lightmeter Project Name: De Anza Center - Tenant Additional Space Enforcement Agency: The City of Cupertino Permit Number: 15050162 Building Department Project Address: 10612 South De Anza Blvd. City: Cupertino Zip Code: 95014 Building: 1 Floor: 1 Room: Showroom Note: Submit one Certificate of Acceptance for each system that must demonstrate compliance. Enforcement Agency Use: Checked by/Date: A: Construction Inspection NA -7.6.1.1 1: Drawing of Daylit Zone(s) must be shown on plans or attached to this form, Select one or both of the following: Shown on plans page #'s E3 Daylit zones(s) drawn in on as -built plans (attached) page #'s Applicable Control System 2.- System Information Zone Type: Skylit (Sky), Primary Sidelit (PS), or Secondary Sidelit (SS) Sky PS SS Control Type: Continuous Dimming with more that 10 light levels (C), Stepped Dimming (SD), Switching (SW) C C Design Footcandle: (enter number or Unknown) unknown fc unknown fc 3.- Sensor and Controls Control Loop Type:Open Loop (OL), Closed Loop (CL) CL CL Sensor Location: Outside (0), Inside Skylight (IS), Near Windows facing out (NW), In Controlled Zone (CZ) CZ CZ Sensor Location is Appropriate to Control Type: (Y/N) If control loop type is Open Loop (OL): Enter yes (Y) if location = Outside (0), Inside Skylight (IS), or Near Windows facing out (NW); otherwise, enter no (N). If control loop type is Closed Loop (CL): Enter yes (y) if location = In Controlled Zone (CZ); otherwise, enter no (N). Yes Yes Control Adjustments are in Appropriate Location (Y/N): Yes, If Readily Accessible or Yes if in Ceiling <= 11 ft, No for all other. Yes Yes 4: Has documentation been provided by the installer. Installation Manuals and Calibration Instructions Provided to Building Owner: (Y/N) Yes Yes Location of Lights Sensor on Plans: (Y/N) Yes Yes Location of Light Sensor on Plans: (Page Number) E3 E3 5.- Seperate Controls of Luminaires In Daylit Zones: Are Luminaires controlled by automatic daylighting controls only in daylit zones (Y/N) Yes Yes Seperately circuited for daylit zones by windows and daylit zones under skylights: (Y/N) Yes Yes 6.- Daylighting control device certification Daylighting control has been certified in accordance with Section 110.9: (Y/N) Yes Yes Construction Inspection Pass/Fail. If all responses on this Construction Inspection are complete and all YES/NO questions have a Yes (Y) response, the tests Pass; if any responses on this page are incomlpete OR there are any No (N) responses, the test Fails Yes Yes If sampling method is used in accordance with NA7.6.1.2, attach a page with names of other controls in sample (only for buildings with > 5 daylight control systems, sample group glazing same orientation) Page 1 of 4 IS, Functional Performance Testing - Continuous Dimming Systems NA-7.6.1.2.1 - Power estimation using light meter measurement System Information a Control Loop Type. Open Loop or Closed Loop? (O or C) C C b Indicate if Mandatory control- M ( required for skylit zone or primary sidelit zone with installed general lighting power >120 W); for Control Credit- CC; or Voluntary not For credit - V (M,CC,V) M V c If automatic daylighting controls are mandatory, are all general lighting luminaires in daylight zones controlled by automatic daylight controls? (Y/N) Yes Yes d Documented general lighting desing footcandle. If design foodcandles not documented leave blank.(Enter fc) e Power estimation method. (see line r) Default ratio of power to light (Dfc), cut-sheet ratio of power to light (CSfc) If CSfc-attach cut-sheet. Enter Dfc or CSfc CSfc CSfc Step 1: Identify Reference Location (location where minimum daylight illuminance is measured in zone served by the controlled lighting.) f Method Used: Illuminance or Distance (I or D) D D Override daylight control system and drive electric lights to full light output for highest light level fc: g Highest light level fc - enter measured controlled electric lighting footcandles (fc) 62.6 fc 61.3 fc h Indicate whether this is Full Output (FO), or Task Tuned (Lumen Maintenance)(TT) FO FO Step 2: No Daylight Test i Method Used: Night time manual measurement (Night), Night Time Illuminance Logging (Log), Cover Fenestration (CF), Cover Open Loop Photosensor (COLP) Night Night j Reference Illuminance (foot-candles) measured at Reference Location (Illuminance of general lighting at the reference location) 58.9 fc 58.9 fc k Enter Y if either of the following statements are true: [Reference Illiminance (line j)] / [Full Output fc (line g)] > 70%? or [Reference Illiminance (line j)] / [design footcandles (line d)] > 80%? (Y/N) Yes Yes Step 3. Full Daylight Test conducted when daylight > reference illuminance (line j) I Daylight illuminance (light level with electric lighting turned off) measured at Reference 67.7 fc Location (fc) 68.6 fc m Daylight illuminance (line 1) greater than Reference Illuminance (line j)? (Y/N) Yes Yes n Fraction controlled wattage turned off. Enter % 39.14% 40.46% o Fraction of controlled wattage dimmed [1-(line n)] 1 60.86% 59.54% Fill out lines p through s only if fraction of controlled wattage turned off (line n) < 100% p Total (daylight + electric light) illuminance measured at the Reference Location (fc) 100 fc 100 fc q Electric lighting illuminance at the Reference Location (fc)[(line p) - (line 1)] 32.30 fc 31.40 fc r Electric lighting illuminance (line q) divided by Highest Light Level fc (line g). Enter % 46.77% 47.54% s Dimmed luminaire fraction of rated power. Attach manufacturer's cut-sheet or use default graph of rated power to light output on bottom of this form. Label applicable control system on cut-sheet or graph. Enter fraction of rated power in %. 54% 56% t System Power Reduction = [1 - (line o) ' (line s)] 67.14% 66.16% u Is System Power Reduction (line t) > 65% when line h = FO, or > 56% when line h = TT (Y/N) Yes Yes v With uncontrolled lights also on, no lamps dimmed outside of daylit zone by control (Y/N) Yes Yes w Dimmed lamps have stable output, no perceptible flicker (Y/N) Yes Yes Step 4 : Partial Daylight Test conducted when daylight between 60% and 95% of (line j) x Daylight illuminance(lightest level without electric light) measured at Reference Location 52 fc 52 fc (fc) y Daylight illuminance divided by the Reference illuminance = (line x) / (line j). Enter %. 88.29% 88.29% z Is Ratio of Daylight illuminance to Ref. illuminance (line y) between 60% and 95% (Y/N) Yes Yes as Total (daylight + electric light) illuminance measured at the Reference Location (fc) 62 fc 62 fc bb Total illuminance divided by the Reference Illuminance = (line aa) /(line j), Enter % 105.26 % 105.26 % cc Is Ratio of Total ilium. to Reference illuminance (line bb) between 100% and 150%? (Y/N) Yes Yes Page 2 of 4 Page 3 of 4 PASS / FAIL Evaluation (check one): 1 PASS: All applicable Construction Inspection responses are complete and all applicable Functional Performance Testing Requirements responses are positive (Y - yes) (applicable questions = c, k, m, u, v, w, z, cc) O FAIL: Any applicable Construction Inspection responses are incomplete OR there is one or more negative (N - no) responses in any applicable Functional Performance Testing Requirements section (applicable questions = c, k, m, u, v, w, z, cc). System does not pass and is NOT eligible for Certificate of Occupancy according to Section 10-103(a)3B. Fix problem(s) and retest until the system(s) passes all portions of this test before retesting and resubmitting NRCA-LTI-03-A with PASSED test to the enforcement agency. Describe below the failure mode and corrective action needed. Page 3 of 4 STATE OF CALIFORNIA AUTOMATIC DAYLIGHTING CONTROL ACCEPTANCE DOCUMENT CEC-NRCA-LTI-03-A (Revised 06/14) CALIFORNIA ENERGY COMMISSION ,�.uLCAA National Lighting Contractors Association of America CERTIFICATE OF ACCEPTANCE - NRCA-LTI-03-A Automatic Daylighting Control Acceptance Document Project Name:: De Anza Center - Tenant Additional Space Enforcement Agency: The City of Cupertino Building Department Permit Number: 15050162 Project Address: 10612 South De Anza Blvd. City: Cupertino Zip Code: 95014 DOCUMENTATION AUTHOR'S DECLARATION STATEMENT I certify that this Certificate of Acceptance documentation is accurate and complete. Documentation Author Name: Documentation Author Signature: Christian Cusella Documentation Author Company Name: Date Signed: February 4, 2016 General Lighting Service Address: 975 Chestnut ave. CEA/HERS/ATT Certification Identification (If applicable): ATT -1503-00023 City/State/Zip: San Jose CA, 95110 Phone: 000-000-0000 FIELD TECHNICIAN'S DECLARED 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 Acceptance is true and correct. 2. 1 am the person who performed the acceptance verification reported on this Certificate of Acceptance (Field Technician). 3. The construction or installation identified on this Certificate of Acceptance complies with the appicable acceptance requirements indicated in the plans and specifications approved by the enforcement agency, and conforms to the applicable acceptance requirements and procedures specified in Reference Nonresidential Appendix NA7. 4. 1 have confirmed that the Certificate(s) of installation for the construction or installation identified on this Certificate of Acceptance has been completed and signed by the responsible builder/installer and has been posted or made available with the building permit(s) issued for the building. Field Technician Name: Field Technician Signature Christian Cusella Field Technician Company Name: General Position with Company (Title): Accepta a Test Te hnicia Lighting Service Address: 975 Chestnut ave. ATT Certification Identification (If applicable): ATT -1503-00023 City/State/Zip: San Jose CA, 95110 1 Phone: 408-761-7967 Date Signed: February 4, 2016 RESPONSIBLE PERSON'S DECLARATION STATEMENT I certify the following under penalty of perjury under the laws of the State of California: 1. 1 am the Field Technician, or Field Technician is acting on my behalf as my employee or my agent and I have reviewed the information provided on this Certificate of Acceptance. 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 Acceptance and attest to the declarations in this statement (responsible acceptance person). 3. The information provided on this Certificate of Acceptance subtantiates that the construction or installation identified on this Certificate of Acceptance complies with the acceptance requirements indicated in the plans and specifications approved by the enforcement agency, and conforms to the applicable acceptance requirements and procedures specified in Reference Nonresidential Appendix NA7. 4. 1 have confirmed that the Certificate(s) of Installation for the construction or installation identified on this Certificate of Acceptance has been completed and is posted or made available witht the building permit(s) issued for the building. 5. 1 will ensure that a completed, signed copy of this Certificate of Acceptance shall be posted, or made available witht 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 Certificate of Acceptance is required to be included with the documentation the builder provides to the building owner at occupancy. Responsible Acceptance Person Name: Responsible Acceptance Person Signatue: Stephen Cusella Responsible Acceptance Person Company Position with Company (Title): Acceptance Test Employer Name: General Lighting Service Address: 975 Chestnut ave. CSLB License: City/State/Zip: San Jose CA, 95110 Phone: 408-298-6670 Date Signed: February 4, 2016 Page 4 of 4