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CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: 15050017 10120 N DE ANZA BLVD CUPERTINO CA 95014 (316 26 097) HOUGH CONSTRUCTION CO INC HOLLISTER, CA 95023 OWNER'S NAME: ROMAN CATHOLIC WELFARE SAN DATE ISSUED: 02/09/2016 OWNER'S PHONE: 408-252-6441 PHONE NO: (831) 636-5827 LICENSED CONTR ACTOR'S D AR ATION BUILDING PERNUT INFO: License Class B Lid. #498686 Contractor HOUGH CONSTRUCTION -CO INC Date 09/30/2016 —BLDG _ ELECT _ PLUMB I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing _ MECH _ RESIDENTIAL _ COMMERCIAL with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. JOB DESCRIPTION: ST JOSEPH SCHOOL - CONSTRUCT NEW OFFICE/TUTORING I hereby affirm under penalty of perjury one of the following two declarations: ROOM (420 SQ FT). 1. I have and will maintain a certificate of consent to self -insure for Worker's DEF#1 - TRASH ENCLOSURE - ISSUED 9/23/16 Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. **TCO GOOD TILL 11/14/2016** I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 ofthe Labor Code, for the performance of the work for which this permit is issued. 12/10/15 PERMITAPPLICATION EXTENDED TILL 02/05/16 Sq. Ft Floor Area: Valuation: $129000.00 APPLICANT CERTIFICATION 1 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 APNNumber: Occupancy Type: and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for 316 26 097 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 PERMIT EXPIRES IF WORK IS NOT STARTED source reg " ns per the Cupertino Municipa -Code, Section 9.18. WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Signature Date 9-23-2016 G t Issued by: Legacy, OWNER -BUILDER DER D T RATION Date: 02/09/2016 I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: RE -ROOFS: 1. I, as owner of the property, or my employees with wages as their sole All roofs shall be inspected prior to any roofing material being installed. If a roof is compensation, will do the work, and the structure is not intended or offered for installed without first obtaining an inspection, I agree to remove all new materials for sale (Sec.7044, Business & Professions Code) inspection. z. I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (See.7044, Business & Professions Code). Signature of Applicant: I hereby affirm under penalty of perjury one of the following three declarations: Date: 9 23-2016 1. 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 ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER performance of the work for which this permit is issued. z. I have and will maintain Worker's Compensation Insurance, as provided for by HAZARDOUS MATERIALS DISCLOSURE Section 3700 of the Labor Code, for the performance of the work for which this I have read the hazardous materials requirements under Chapter 6.95 of the permit is issued. California Health & Safety Code, Sections 25505, 25533, and 25534. I will 3. I certify that in the performance of the work for which this permit is issued, I maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the shall not employ any person in any manner so as to become subject to the Health & Safety Code, Section 25532(a) should I store or handle hazardous Worker's Compensation laws of California. If, after making this certificate of material. Additionally, should I use equipment or devices which emit hazardous exemption, I become subject to the Worker's Compensation provisions of the air contaminants as defined by the Bay Area Air Quality Management District I Labor Code, I must forthwith comply with such provisions or this permit shall will maintain compliance with t e ertino Municipal Code, Chapter 9.12 and 25505,P533, be.deemed revoked. the Health &Safety ode, ections and [2/-6`34. APPLICANT CERTIFICATION Owner or authorized agen . 4 I certify that 1 have read this application and state that the above information is Date: 9-23-2016 V 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 I hereby affirm that there is a construction lending agency for the performance to enter upon the above mentioned property for inspection purposes. (We) agree of work's for which this permit is issued (Sec. 3097, Civ C.) to save indemnify and keep harmless the City of Cupertino against liabilities, Lender's Name judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands Lender's Address and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Signature Date 9-23-2016 Licensed CONSTRUCTION PERMIT APPLICATION f COMMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 buildin-gPcupertino.om ❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION / TI REVISION / DEFERRED ORIGINAL PERMIT # PROJECT ADDRES62 N. 9 or APN #� OWNER NAME R PAP 1`fo / �t7tA#67 s) oS y10g Z E lc'l?Ae .�� S Csc oa r STREET ADDRESS®/ ZO z CITY, STATE, ZI� aP ,4 c7rQ FAX CONTACT NAME EMAIL /,Goa ' ST ET ADEN CITY, STATE, ZIP f FAX ❑ OWNER ❑ OWNER -BUILDER 11 OWNERAGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ARCHITECT 0 ENGINEER ❑ DEVELOPER. ❑ TENANT - CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS. LIC # COMPANY NAME l ®A E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARCHITECT/E ER E LICENSE NUMBER BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK EXISTING USE PROPOSED USE CONSTR TYPE # STORIES USE TYPE OCC. SQ.FT. VALUATION ($) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH ❑ATTACH # DWELLING UNITS: IS A SECOND UNIT ❑ YES SECOND STORY ❑ YES s/ BEING ADDED? ❑ NO ADDITION? ONO PRE -APPLICATION F1 YES IF YES, PROVIDE COPY OF ISTHEBLDGAN El YES RECEIVEI?$TOTAL VALUATION: PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER EICHLER HOME? ❑ NO n , By my signature below, I certify to each of the following: I am the property owner or authorized ageAt to R on the properly owner's behalf. I have read this application and the information I have provided is correct. I have read the Description of Work and verify i is accurate. I agree to comply with all applicable local ordinances and state laws relating to building cons5action. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes. Signature of Applicant/Agent: V _ Date: 3-019214 L SUPPLEMENTAL INFORMATION REQUIRED P A 1�4 TYPTS�>. .v RouTiNG SLIP New SFD or Multifamily dwellings: Apply for demolition permit for ❑, OVERTIiE-CODNTER ❑ BUIIT?INGPLANREViEw existing building(s). Demolition permit is required prior to issuance of building ; permit for new building. ' EXPItES& ❑ LANNINGPLANREVIEW © Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑.; s�ANDasD ", ❑I>BLIC vioxxs` form if any Hazardous Materials are being used as part of this project. LARGE::: F7REDEP3``•'� _ Copy of Planning Approval Letter or Meeting with Planning prior to ©"SANITARY swRDISTRICT submittal of Building Permit application. �� '� ❑�E1SVri20N�IEN'12SI,HEALTH . ,f,%., B1dgApp_2011.doc revised 06121111 CITY OF CUPERTINO BUILDING PERMIT BUILDINGADDRESS: CONTRACTOR: PERMIT NO: 15050017 10120 N DE ANZA BLVD CUPERTINO CA 95014 (316 26 097) ( HOUGH CONSTRUCTION CO INC) HOLLISTER, CA 95023 OWNER'S NAME: ROMAN CATHOLIC WELFARE SAN DATE ISSUED: 02/09/2016 OWNER'S PHONE: 408-210-2019 PHONE NO: 831-636-5827 LICENSED CONMCTOR'S DECLARATION BUILDING PERMIT INFO: License Class B Lic. #498688 Contractor (..HOUGH CONSTRUCTION CO INC ) Date 219/2016 —BLDG _ELECT _PLUMB I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing MECH _ RESIDENTIAL _ COMMERCIAL with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. JOB DESCRIPTION: ST JOSEPH SCHOOL - CONSTRUCT NEW OFFICE/TUTORING I hereby affirm under penalty of perjury one of the following two declarations: ROOM (420 SQ FT). 1. 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. Sq. Ft Floor Area: Valuation: $129000.00 APPLICANT CERTIFICATION certify that I have read this application and state that the above information is correct. I agree to comply with all city and county APN Number: Occupancy Type: ordinances and state laws relating to building construction, and hereby 316 26 097 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 PERMIT EXPIRES IF WORK IS NOT STARTED expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will WITHIN 180 DAYS OF PERMIT ISSUANCE OR comply with all non -point source regulations per the Cupertino Municipal 180 DAYS FROM LAS CALLED INSPECTION. Code, Sectio 8. t Issued by: PAUL O SULLIVAN vS ULL I I/nr `° Signature Date 22/9/2016 Date: 2/9/2016 OWNER -BUILDER DECLAR ATION RE -ROOFS: I hereby affirm that I am exempt from the Contractor's License Law for one of the All roofs shall be inspected prior to any roofing material being installed. If a roof is following two reasons: installed without first obtaining an inspection, I agree to remove all new materials for 1. I, as owner of the property, or my employees with wages as their sole inspection. compensation, will do the work, and the structure is not intended or offered for sale (Scc.7044, Business & Professions Code) Signature of Applicant: 2. I, as owner of the property, am exclusively contracting with licensed Date: 2/9/2016 contractors to construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER I. 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 HAZARDOUS MATERIALS DISCLOSURE performance of the work for which this permit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the 2. I have and will maintain Worker's Compensation Insurance, as provided for California Health & Safety Code, Sections 25505, 25533, and 25534. I will by Section 3700 of the Labor Code, for the performance of the work for which maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the this permit is issued. Health & Safety Code, Section 25532(x) should I store or handle hazardous a. I certify that in the performance of the work for which this permit is issued, I material. Additionally, should I use equipment or devices which emit hazardous. shall not employ any person in any manner so as to become subject to the 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 Worker's Compensation laws of California. If, after making this certificate of . the Health & Safety. Co Sectio 533, and 255 exemption, I become subject to the Worker's Compensation provisions of the W50 / Labor Code, I must forthwith comply with such provisions or this permit shall Owner or authorized agent be deemed revoked. Date:/2 9/20.16 f APPLICANT CERTIFICATION CONSTRUCTION LE IN G A Y I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance correct. I agree to comply with all city and county ordinances and state laws of work's for which this permit is issued (Sec. 3097, Civ C.) relating to building construction, and hereby authorize representatives of this city Lender's Name to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, Lender's Address judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant ARCHITECT'S DECLARATION understands and will comply with all non -point source regulations per the I understand my plans shall be used as public records. Cupertino Municipal Code, Section 9.18. Licensed Professional Signature Date/2 �?Q/ 16 o f 7 CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 }CUPERTiNO• (4018)1777-3228•• FAX (408) 777-3333 • building(L cugertino.ora J°l 7W C'nNCTRT.TrTTCIN I 8) I AT)T)TTT... 1 r1 eTTT'uATTnKT/TT F-1 T)T:XrTQTnXT/71�CLDDCT hnrnn.r�r r PROJECT ADDRESS vy eg 0 ` � / l.�%C _ OWNER NAME `✓L PHO�.yNamF- E-MAIL Zm) aff 'efO Z016-) W1,6 -A1 L.%bL- Sle-ScWw( L, STREET ADDRESS W ISO pi, ()0 NSA 711-4c'Ty rrHaA�'���Z. ! m (d P, FAX NAME �'h�L�y� ` 2' t �4n* PHO12( _2_'5tE -MAIIL p --0 / Z STREET ADDRESS j @�® CITY, STATE, ZIP t ^� FAX El OWNER ❑ OwNER-BUILDER ❑ OWNERAGENT 11 CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTORNAME LICENSE NUMBER LICENSE TYPE BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARMH�TEC4T/ENIIPEEt �NAMEi /�" E LICENSE NUMBERC®� L� ` BUS. LIC # COMP(,_, NAME J � q s, � Z Z �y`/�1(�s�. � EMti��i� G FAX6 � L� 6s° U C7 C " - -u /moi CITY OF CUPERTINO UU-Vi Ti CrI'TM A 9rnI2 _ RITTT .11TNG 11IVIRION ADDRESS: 10120 N DE ANZA BLVD DATE: 05/05/2015 REVIEWED BY: MELISSA APN: 316 26 097 BP#: *VALUATION: $129,000 PERMIT TYPE: Building Permit PLAN CHECK TYPE: New Construction PRIMARY Commercial Building Civil / Religious activities 0 Yes No PENTAMATION 1 BOFF PERMIT TYPE: USE: in BQ zone? Permit Fee: WORK JOSEPH SCHOOL - CONSTRUCT N OFFICE/TUTORING ROOM 420, S.F. 0,0 �ST SCOPE T= OCCUPANCY TYPE: TYPE OF FLR AREA PC FEES PC FEE ID BP FEES BP FEE ID CONSTR. s.L B (Offices) I1-B,I11-B,IV,V-B 420 $5;979.00 1BOPLNCK $1,824.00 1BOINSP TOTALS: 420 $5,979.00 f $1,824.00 NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer' District, School District, etc). These fees are based on the preliminary information available ana are .oncy an esumare. t-untav, -te xept tv, asuac.c FEE ITEMS Lee Resolution 11-053 Eff. 711113? FEE QTY/FEE MISC ITEMS Plan Check Fee: $5,979.00 Select a Misc Bldg/Structure or Element of a Building Suppl. PC Fee: Q Reg. Q OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $1,824.00 Suppl. Insp. Fee -.(j) Reg. Q OT 0,0 I hrs $0.00 T= PME Unit Fee: $0.00 PME Permit Fee: $0.00 T= Construction Tax: 1BCONST.9XC $1,230.60 Administrative.dee 0 T ®I Work Without Permit? 0 Yes G No $0.00 Advanced Planning Fee: IPLLONGC $121.80 Select a Non -Residential E) Building or Structure O 'A Travel avicel Doc�umentatican 14' �>s: Strong Motion Fee: IBSEISMICO $36.12 Select an Administrative Item Bldg Stds Commission Fee IBCBSC $6.00 TTAz= $9,197.52 $0.00= $9,197.52 �� .. v _ - __ —_ = y Revised: 04/01/2015 CUPERTINO CONTRACTOR / SUBCONTRACTOR LIST Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 Fax: 408-777-3333 *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 Date Please check applicable subcontractors and complete the following information: V SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork au�f Cwt 8 Cement Finishing t4-2-7-1 Electrical Excavation # Fencing Flooring / Carpeting c v J t' a— Linoleum / Wood B c pW,v�2 a Glass / Glazing -Q G Heating , : (3 : --I �' G, Z cl Insulation �yd�., � C , # 7 pp 1t1ffl"wP411g Lathingpj3 VOZ �LA b # .3 3 6 44 Masonry Painting / Wallpaper va6• � - b Paving Plastering 9M3 VO I -A-57-1='2 � Cob # ,- Plumbing tA�47YR QW4A 17Y2. Roofing L , G i Septic Tank Sheet Metal c_ X 6 �/2 Sheet Rock G•a r7 CIS R Tile , Date 'STATE 07 CALIFORNIA ENERGY MANAGEMENT CONTROL SYSTEM OR LIGHTING CONTROL SYSTEM CEC-NRCI-LTI-02-E (Revised 12/15) CALIFORNIA ENERGY COMMISSION CERTIFICATE OF INSTALLATION NRCI-LTI-02-E Energy Management Control System or Lighting Control System (Page 1 of 6) Project Name: `,� /� _ Enforcement Agen er ittNN�e0 11 Project Address: 1 n ^ r Dg w _' I _ City: W 1p Afiff f pa clk • o GENERAL INFORMATION Enter the date of approval by enforcement agency of the Certificate of Compliance that provides DATE OF BUILDING PERMIT Z -q- Ito the specifications for the energy efficiency measures for the scope of responsibility for this PERMIT # �SoSoo I� - BUILDING TYPE Nonresidential ❑ High -Rise Res (Common Area) ❑ Hotel/Motel (Common Area) PHASE OF XNew Construction ❑ Addition ❑ Alteration ❑ Unconditioned CONSTRUCTION SCOPE OF RESPONSIBILITY Enter the date of approval by enforcement agency of the Certificate of Compliance that provides Date: the specifications for the energy efficiency measures for the scope of responsibility for this L Installation Certificate. Requirements in the Standards: §130.4(b) Before an Energy Management Control System (EMCS), or Lighting Control System can be recognized for compliance with the lighting control requirements in Part 6 of Title 24, the personwho is eligible under Division 3 of the Business and Professions Code to accept responsibility for the construction or installation of features, materials, components, or manufactured devices shall sign and submit this Installation Certificate. If any of the requirements in this Installation Certificate fail the Energy Management Control System or Lighting Control System installation requirements, these options for controlling lighting shall not be recognized for compliance with the Building Energy Efficiency Standards. Check all that apply: PART 1 What type of Lighting Control System has been installed? ❑ A. Energy Management Control System (EMCS) - Is a comput ' ed control system designed to regulate the energy consumption of a building by controlling the ope on of energy consuming systems, such as the heating, ventilation and air conditioning (HVAC), lighting, a ater heating systems, and is capable of monitoring environmental and system loads, and adjusti VAC operations in order to optimize energy usage and respond to demand response signals. ❑ The Energy ManagementC trol System has been installed to function as a lighting control required by Part 6 and functionally m s all applicable requirements for each application for which it is installed, in accordance with ctions 110.9, 130.0 through 130.5, 140.6 through 150.0, and 150.2; and complies with Reference residential Appendix NA7.7.2. ❑ Th CS has been separately tested for each respective lighting control system for which it is installed to unction as. B. Lighting Control System - Requires two or more components to be installed in the building to provide all of the functionality required to make up a fully functional and compliant lighting control. The installed Lighting Control System complies with the requirements checked below; and all components of the system considered together as installed meet all applicable requirements for the application for which they are installed as required in Sections 130.0 through 130.5, Sections 140.6 through 140.8, Section 141.0, and Section 150.0(k). CA Building Energy Efficiency Standards - 2013 Nonresidential Compliance December 2015 STATE 0; CALIFORNIA ENERGY MANAGEMENT CONTROL SYSTEM OR LIGHTING CONTROL SYSTEM Par, _AIDrI_I ri n2c rD—A—A 1�/lr;CAI X()RNIA FNF:PrY CnMMISSIr)N CERTIFICATE OF INSTALLATION NRCI-LTI-02-E Energy Management Control System or Lighting Control System (Page 2 of 6) Project Name: Hs 41�?9 14 - 1 n I , • — Enforcement Agency: ` ` Proje Addr s , w -'I _ City. w� � A -T% 4c) zip OI PART 2 Lighting Control Functional requirements: Check all that apply when verifying the installation of an EMCS or Lighting Control System. A. All lighting controls and equipment have been installed in accordance with the manufacturer's instructions. B. The manufacturer has provided instructions for calibration. C. If indicator lights are integral to any components, such indicator lights consumes no more than 1 watt of power per indicator light. 9K D. Components that are regulated by the Title 20 Appliance Efficiency Regulations have been certified to the Energy Commission. ❑ E. The EMCS or Lighting Control System functions as one or more of the Time -Switch Lighting Controls checked below, and complies with all of the following requirements: ❑ 1. Automatic Time -Switch Controls meeting all requirementr Automatic Time Switch Control devices in the Title 20 Appliance Efficiency Regulations, including requirements below: a. Residential automatic time-switch,26trols have program backup capabilities that prevent the loss of the device's schedule at least 7 days, and the device's date and time for at least 72 hours if power is interru ed. b. Commercial auto m c time -switch controls meet the following requirements: i. Ha rogram backup capabilities that prevent the loss of the device's schedule for at least days, and the device's date and time for at least 72 hours if power is interrupted; Is capable of providing manual override to each connected load and shall resume normally scheduled operation after manual override is initiated within 2 hours for each connected load; and iii. Incorporates an automatic holiday shutoff feature that turns off all connected loads for at least 24 hours and then resumes normally scheduled operation. ❑ 2. Astronomical Time -Switch Controls meeting all requirements for Astronomical Time -Switch Control devices in the Title 20 Appliance Efficiency Regulations, including the requirements below: a. Meets the requirements of an automatic time- Witch control; b. Has sunrise and sunset prediction accurac ithin plus -or -minus 15 minutes and timekeeping accuracy within 5 minutes per year; c. Is capable of displaying date, cur t time, sunrise time, sunset time, and switching times for each step during programmi d. Has an automatic daylig savings time adjustment; and e. Has the ability to ind endently offset the on and off for each channel by at least 99 minutes before and after nrise or sunset. ❑ 3. Multi -Level Astr nomical Time -Switch Controls, in addition to meeting all of the requirements for Astronomical Tie-Switch Controls, includes at least 2 separately programmable steps per zone. ❑ F. The EMCS ighting Control System functions as one or more of the Daylighting Controls listed below: CA Building Energy Efficiency Standards - 2013 Nonresidential Compliance December 2015 -STATE OF CALIFORNIA ENERGY MANAGEMENT CONTROL SYSTEM OR LIGHTING CONTROL SYSTEM rrr'-K1 rzri_i Tt_r»_c rao A—i 4-3111; RAI IFnRNIA FNFRr Y Cr)MMISSION CERTIFICATE OF INSTALLATION NRCI-LTI-02-E Energy Management Control System or Lighting Control System (Page 3 of 6) Project Name: -SF /r6,� //V�. JQ. Enforcement Ag cy_ N W, `_ —w n �T>DYG-T1*,0 �j �%N:L P;,^Prt ,,w :N^ 1 Prove eu: tse City: Z`ipCgee5,, ❑ 1. Automatic Daylight Controls meet all requirements for Automatic Daylight Control devices in the Title 20 Appliance Efficiency Regulations, including the following: a. Is capable of reducing the power consumption in 7responso measured daylight either directly or by sending and receiving signals; b. If the system includes a dimmer, complies with he Dimmer Control device requirements in the Title 20 Appliance Efficiency Regulations. c. Automatically return to its most rece time delay settings within 60 minutes when put in calibration mode; dX,a et point control that sily distinguishes settings to within 10 percent of full scale ent; eght sensor t t has a linear response within 5 percent accuracy over the range of ance m ured by the light sensor; f.ght nsor thatis physically separated from where the calibration adjustments are made, ble of being calibrated in a manner that the person initiating the calibration is remote e sensor during calibration to avoid influencing calibration accuracy; and ges with the Title 20 requirements for photo controls if the system contains a photo control component. ❑ 2. Photo Controls meet all requiremenor Photo Control devices in the Title 20 Appliance Efficiency Regulations, including the followin at it does not have a mechanical device that permits disabling of the control. ❑ G. The EMCS or Lighting Control System functions as a Dimmer and meets all requirements for a Dimmer Control device in the Title 20 Appliance Efficiency Regulations,i ing the following: 1. Is capable of reducing power consumpti y a minimum of 65 percent when the dimmer is at its lowest level; 2. Includes an off position w=nl oduces a zero lumen output; and 3. Does not consume moreatt per lighting dimmer switch leg when in the off position. 4. Dimmer controls th can directly control lamps provide electrical outputs to lamps for reduced flicker operation thro the dimming range so that the light output has an amplitude modulation of less than 30 perce or frequencies less than 200 Hz without causing premature lamp failure. 5. If des' ed for use in three way circuits is capable of turning lights off, and to the level set by the dimmer if the lights are off. H. The EMCS or Lighting Control System meets the following requirements: 1. Is capable of automatically turning off controlled lights in the area no more than 30 minutes after the area has been vacated; 2. Allows all lights to be manually turned off regardless of the status of occupancy; and 3. Has a visible status signal that indicates that the device is operating properly, or that it has failed or malfunctioned. The visible status signal may have an override switch that turns off the signal. 4. All occupant sensing devices that utilize ultrasonic radiation for detection of occupants meet the Ultrasound Maximum Decibel Values in the Title 20 Appliance Efficiency Regulations 5. All occupant sensing devices that utilize microwave radiation for detection of occupants meet the radiation requirements in the Title 20 Appliance Efficiency Regulations 6. Occupant sensing devices incorporating dimming comply with the requirements for dimmer controls in the Title 20 Appliance Efficiency Regulations CA Building Energy Efficiency Standards - 2013 Nonresidential Compliance December 2015 "STATE GF CALIFORNIA ENERGY MANAGEMENT CONTROL SYSTEM OR LIGHTING CONTROL SYSTEM rFGNRrl-I TI_n9_F 1P- i 1 1 i9/151 (.Al IFnRNIA FNFRrV r.nMM19SInN CERTIFICATE OF INSTALLATION NRCI-LTI-02-E Energy Management Control System or Lighting Control System (Page 4 of 6) Pro!et P : �J& J /��� /� 1 .11vir��� Enforcement!VR /� 1e,$,�n� rail0 -^ ' Project Address: n_W V Nom' City:ZGi' l oS o 1v 7. The EMCS or Lighting Control System functions as one or more of the Occupant Sensing Controls Checked Below: a. Occupant Sensors meeting all applicable requirements for Occupant Sensor Control devices in the Title 20 Appliance Efficiency Regulations b. Motion Sensors meeting all applicable requirements for Motion Sensor Controls devices in the Title 20 Appliance Efficiency Regulations, including that motion sensors are rated for outdoor use. ❑ c. Vacancy Sensors meeting all applicable requirements for Vaca/Seor Controls devices in the Title 20 Appliance Efficiency Regulations, including the followin i. Does not turn on lighting automatically and does not inc porate DIP switches, or other manual means, for conversion between manual and tomatic functionality; ii. Has a grace period of no more than 30 seconds d no less than 15 seconds to turn on lighting automatically after the sensor has ti d out; and iii. Does not have an override switch that di les the sensor. ❑ d. Partial -ON Sensors meeting all applicable quirements for partial on sensing devices in the Title 20 Appliance Efficiency Regulations, i uding the following: i. Has two poles each with auto tic -off functionality; ii. Has one pole that is manua on and does not incorporate DIP switches, or other manual means, for conversion b ween manual and automatic functionality; and iii. Has one pole that is tomatic-on and is not be capable of conversion by the user to manual -on functi ality. ❑ e. Partial -OFF Sensors eet all applicable requirements for partial off sensing devices in the Title 20 Appliance Efficien Regulations, including the following: i. Has two p es; ii. Has on pole that is manual -on and manual off; and iii. Has a pole that is automatic -on and automatic -off and is not capable of conversion by th user to manual -on only functionality. ❑ f. Occ ant Sensing Control systems consist of a combination of single or multi-level Occupant, Motio , or Vacancy Sensor Controls, and all components installed to comply with manual -on requirements are not capable of conversion by the user from manual -on to automatic -on functionality. CA Building Energy Efficiency Standards - 2013 Nonresidential Compliance December 2015 STATE OF CALIFORNIA ENERGY MANAGEMENT CONTROL SYSTEM OR LIGHTING CONTROL SYSTEM Tl_r19_C [P—A 4 19/111 CAI IFnRNIA FNF:PrY COMMISSInN CERTIFICATE OF INSTALLATION NRCI-LTI-02-E Energy Management Control System or Lighting Control System (Page 5 of 6) Project Name: L�-V 7 Enforcement Agency: Perrrrt N r: P oleoress: City. P --T ' +' C 0 PART 3 Requirements for which the control is being installed to complied with: Identify all requirements in the Standards for which the EMCS or Lighting Control System is installed to function as and complies with: Check all that are applicable A. Section 130.1(a) Area Controls. E3 B. Section 130.1(b) Multi -Level Lighting Controls `_C. Section 130.1(c) Shut -OFF Controls E3 D. Section 130.1(d) Automatic Daylighting Controls. E. Section 130.1(e) Demand Responsive Controls. Q F. Section 130.5 (d) Circuit Controls for 120 -Volt Receptacles. If installed to qualify for a Power Adjustment Factor mit this Installation Certificate in addition to the PAF Installation Certificate. ❑ G. To qualify for the PAF for a Partial- Occupant Sensing Control in TABLE 140.6-A ❑ H. To qualify for the PAF for an upant sensing control controlling the general lighting in large open plan office areas above workstations, ' ccordance with TABLE 140.6-A I. To qualify for the for a Manual Dimming System PAF or a Multiscene Programmable Dimming System PAF in TABLE 140.6-A 0 J. To quay for the PAF for a Demand Responsive Control in TABLE 140.6-A K. To alify for the PAF for Combined Manual Dimming plus Partial -ON Occupant Sensing Control in TABLE 140.6-A CA Building Energy Efficiency Standards - 2013 Nonresidential Compliance December 2015 'STATE OF CALIFORNIA ENERGY MANAGEMENT CONTROL SYSTEM OR LIGHTING CONTROL SYSTEM rGr_niQri_i T1_n9_C IP—A—i 191111 RAI IFORNIA FNFRrV COMMISSION CERTIFICATE OF INSTALLATION NRCI-LTI-02-E Energy Management Control System or Lighting Control System (Page 6 of 6) Project Name: � s ,� /� _ / Enforcement Agency: Perm' um Pr eR A ss: p . _,_,i ^ City: ese Co 14 O DOCUMENTATION AUTHOR'S DECLARATION STATEMENT 1. 1 certify that this Certificate of Installation documentation is accurate and complete. Documentation Author Name: I Documentatio ut o ignature: Documentation Author Compa y Name: nf"fint— Date Signed: 9-11-1611 Address: CEA Certification Iden ' ationIf app'cab'le Ci /Sta /Zips. C&' 1k���� Phone: ✓�� J RESPONSIBLE PERS N'S DECLARATION STATEMENT I certify the following under penalty of perjury, under the laws of the State of California: 1. The information provided on this Certificate of Installation is true and correct. 2. 1 am eligible under Division 3 of the Business and Professions Code in the applicable classification to accept responsibility for the system design, construction, or installation of features, materials, components, or manufactured devices for the scope of work identified on this Certificate of Installation and attest to the declarations in this statement (responsible builder/installer), otherwise I am an authorized representative of the responsible builder/installer. 3. The constructed or installed features, materials, components or manufactured devices (the installation) identified on this Certificate of Installation conforms to all applicable codes and regulations, and the installation conforms to the requirements given on the plans and specifications approved by the enforcement agency. 4. 1 reviewed a copy of the Certificate of Compliance approved by the enforcement agency that identifies the specific requirements for the scope of construction or installation identified on this Certificate of Installation, and I have ensured that the requirements that apply to the construction or installation have been met. 5. 1 will ensure that a completed signed copy of this Certificate of Installation shall be posted, or made available with the building permit(s) issued for the building, and made available to the enforcement agency for all applicable inspections. I understand that a completed signed copy of this Certificate of Installation is required to be included with the documentation the builder provides to the building owner at occupancy. Responsiolp Buil` r Instal, IeANamw,e: Responsibl 'Ider/Inst Signature: Company Name: (Installing Subcontractor or General Contractor or Position VQth Company Title): Builder/Owner) Address,n CSLB License: ��^ t9 ^Vao Cit State Zip: �i� 51 r7-- OIL P o �V �23 DT CA Building Energy Efficiency Standards - 2013 Nonresidential Compliance December 2015 STATE OF CALIFORNIA LIGHTING CONTROL ACCEPTANCE DOCUMENT(ja cFr_Nacn_i Ti_m-A fao.,i—I Oeriri CALIFORNIA ENERGY COMMISSION CERTIFICATE OF ACCEPTANCE NRCA-LTI-02-A Lighting Control Acceptance Document (Page 1 of 5) Project Name: Enforcement Agency: V �— s P�rmft1J ru L:� '-7 55 SS Project Address: t 0vW . D�' A -+J '�uJ �D city: W V' -'o30 Zip C 50 l Note: For more than 3 spaces attach additional sets of pages 2 Enforcement Agency Use: Checked by/Date through 5, as required. Automatic Shut-off Controls: Automatic Time Switch Control and Occupant Sensor Intent: I Lights are turned off or set to a lower level when not needed per Section 110.9(0) & 130.1(c). Guidance This acceptance test compliance document must be filled out for all newly -installed lighting control systems of the following types: I. Automatic Time Switch Controls II. Occupancy Sensors --- III. Partial -OFF occupancy sensors IV. Partial -ON occupancy sensors V. Occupancy Sensors serving small zones in large open plan offices (only if used to claim a Power Adjustment Factor) For automatic daylighting controls use acceptance test compliance document NRCA-LTI-03-A; for demand responsive lighting controls, use acceptance test compliance doucment NRCA-LTI-04-A. The tests on this certificate are required by Section 140.6(a)2 and 130.4(a) of the 2016 Building Energy Efficiency Standards . The tests themselves are described in Sections 140.6(a)2 and in Reference Appendix NA7.6. A. Construction Inspection Fill out Section A to cover spaces 1 through 3 that are functionally tested under Section B. Make as many copies of pages 2-5 as are required to test all spaces in the building, and attach to page 1. Instruments needed to perform tests ' lude, but are not limited to: hand-held amperage meter, power meter, or light meter 01 Automatic Time Switch trols Construction Inspection—confirm for all listed in Section B a• All automatic timeitch controls are programmed for (check all): ❑ W days Weekend Holidays b. Document for the owner automatic time switch programming (check all): ❑ Weekdays settings ❑ Weekend settings ❑ Holidays settings ❑ Set-up settings ❑ Preference program setting ❑ Verify the correct time and date is properly set in the time switch ❑ Verify the battery is installed and energized ❑ Override time limit is no more than 2 hours Occupant Sensors and Automatic Time Switch Controls have been certified to the Energy Commission in accordance with the applicable provision in Section 110.9 of the Standards, and model numbers for all such controls are listed on the Commission database as Certified Appliance and Control Devices 02 Occupancy Sensor Construction Inspection—confirm for all listed in Section B Occupancy sensors are not located within 4 feet of any HVAC diffuser Ultrasonic occupancy sensors do not emit audible sound 5 feet from source 9 CA Building Energy Efficiency Standards - 2016 Nonresidential Compliance April 2016 STATE OF CALIFORNIA LIGHTING CONTROL ACCEPTANCE DOCUMENT AZ C'Fr-NRrA-j TI -02-A (RPvigPd 04/16) CALIFORNIA ENERGY COMMISSION CERTIFICATE OF ACCEPTANCE NRCA-LTI-02-A Lighting Control Acceptance Document (Page 2 of 5) Project Name: Enforcement A envy: Perm' t Project Address: o -A 0. Its W 2� W0 City: WY - X00 Zip de: 0 B. Functional Testing of Lighting Controls Representative Spaces Selected For every space in the building, conduct functional tests 1 through 5 below if applicable. If there are several geometrically similar spaces that use the same lighting controls, test only one space and list in the cells below which "untested spaces" are represented by that tested space. EXCEPTION: For buildings with up to seven (7) occupancy sensors, all occupancy sensors shall be tested.(NA7.6.2.3) Tested space/ room name: C��t(AV� Space Type (office, corridor, etc) Ofyt, 01 Untested areas/rooms .. 11 Tested space/ room name'7r 1J� Space Type (office, corridor, etc)�NM � W� 02 Untested areas/rooms Tested space/ room name: Space Type (office, corridor, etc) 03 Untested areas/ro Orrrs Functional Tests Tested Space Number Confirm compliance (Yes/No) for all control system types (1-5) present in each space: 01. Automatic Time Switch Controls 1 2 3 Step 1: Simulate occupied condition a. All lights can be turned on and off by their respective area control switch b Verify the switch only operates lighting in the ceiling -height partitioned area in which the switch is located Step 2: Simulate unoccupied condition a' All lighting, including emergency and egress lighting, turns off. Exempt lighting may remain on per Section 130.1(c)1 and 130.1(a)1. Manual override switch controls only the lights in the selected ceiling height b partitioned space where the override switch is located and the lights remain on no longer than 2 hours (unless serving public areas and override switch is captive key type). Step 3: System returned to initial operating conditions 02. Occupancy Sensors 1 2 3 Step 1: Simulate an unoccupied condition Lights controlled by occupancy sensors turn off within a maximum of 20 minutes a' from start of an unoccupied condition per Standard Section 110.9(b) b' The occupant sensor does not trigger a false "on" from movement in an area adjacent to the controlled space or from HVAC operation Step 2: Simulate an occupied condition a. Status indicator or annunciator operates correctly Lights controlled by occupancy sensors turn on immediately upon an occupied b. condition OR sensor indicates space is "occupied" and lights may be turned on manually Step 3: System returned to initial operating conditions I CA Building Energy Efficiency Standards - 2016 Nonresidential Compliance April 2016 STATE OF CALIFORNIA LIGHTING CONTROL ACCEPTANCE DOCUMENT rFc_NRrA.i TI -09-A [P—i I nd/1Rl CALIFORNIA ENERGY COMMISSION CERTIFICATE OF ACCEPTANCE NRCA-LTI-02-A Lighting Control Acceptance Document (Page 3 of 5) Prgjec[ Name� Enforcement Agency: ,� _ _ I�� �' Q�Gvrr` Pe�f�ywrb50%1 Ji Project Address: City: Co 03. Partial Off Occupancy Sensor 1 2 3 Step 1: Simulate an unoccupied condition Lights go to partial off state within a maximum of 20 minutes from start of an a' unoccupied condition per Standard Section 110.9(a) The occupant sensor does not trigger a false "on" from movement in an area adjacent b to the controlled space or from HVAC operation. For library book stacks or warehouse aisle, activity beyond the stack or aisle shall not activate the lighting in the aisle or stack. In the partial off state, lighting shall consume no more than 50% of installed lftakenl power, or: • No more than 60% of installed lighting power for metal halide or hi pressure sodium lighting in warehouses. C. • No more than 60% of installed lighting power for corridors an air which the installed lighting power is 80% or less of the val allowe the Area Category Method. Light level may be used as a proxy for lighting power when easurements ar Step 2: Simulate an occupied condition The occupant sensing controls shall turn lights full N in each separately controlled a' areas, Immediately upon an occupied conditiqW 04. Partial On Occupancy Sensors 1 2 3 Step 1. -Simulate an occupied Condit' . Verify partial on operation. Immediately upon an occu ' d condition, the first stage activates between 50 to 70% a' of the lighting automati ly. After the first stage curs, manual switches allow an occupant to activate the b. alternate set of I' ts, activate 100% of the lighting power, and manually deactivate all of the lig Step 2. SimulkCan unoccupied condition Both ages (automatic on and manual on) lights turn off within a maximum of 20 a. m' utes from start of an unoccupied condition per Standard Section 110.9(a) b' he occupant sensor does not trigger a false "on" from movement in an area adjacent to the controlled space or from HVAC operation. CA Building Energy Efficiency Standards - 2016 Nonresidential Compliance April 2016 STATE OF CALIFORNIA LIGHTING CONTROL ACCEPTANCE DOCUMENT CEC-NRCA-LTI-02-A Revised 04116 CALIFORNIA ENERGY COMMISSION CERTIFICATE OF ACCEPTANCE NRCA-LTI-02-A Lighting Control Acceptance Document (Page 4 of 5) Project N^� r Iw\ Enforce ent cy:l Permit Num �—I 55 Pr(- Address: ^, ��•�— J ,� _ 1 ^ City: W2D� ` O Zip '150 LA 05. Additional test for Occupancy Sensors Serving Small Zones in Office S Larger 1 2 3 than 250 ft2'to Qualify for a Power Adjustment Factor (PAF) FAIL 1 Automatic Time Switch Controls (all answers must be Yes). First, complete Functional Test 2 (above) for each controlled zon Step 1. Verify area served and compare actual PAF with cl ed PAF. Refer to Functional Test II. a. Area served by controlled lighting (ft) 3 Partial Off Occupancy Sensor (all answers must be Yes). For warehouses, library book stacks, corridors, stairwells in nonresidential buildings must also be Enter PAF corresponding to controlled ar rom line (a) above (<125 ft for PAF=0.4, accompanied by passing Test I or Test II. b. 126-250 ftZfor PAF=0.3, 251-500 ftZf AF=0.2). 5 Occupant Sensor serving small zones for PAF (all answers must be Yes). Also must Enter PAF claimed for occupant nsor control in this space from the Certificate of pass Test II. C. Compliance. d The PAF correspondin the controlled area (line b), is greater than or equal to the PAF claimed in the mpliance documentation (line c). Sensors shall n trigger in response to movement in adjacent walkways or e' workspace . All ste are conducted in Functional Test 2 "Occupancy Sensor (On Off Control)" f' an I answers are Yes. D. Evaluation ❑ PASS: All applicable Construction Inspection responses are complete and all applicable Equipment Testing Requirements responses are positive (Y - yes). CA Building Energy Efficiency Standards - 2016 Nonresidential Compliance April 2016 PASS / PASS / PASS / C. Testing Results FAIL FAIL FAIL 1 Automatic Time Switch Controls (all answers must be Yes). 2 Occupancy Sensor (On Off Control) (all answers must be Yes). 69-5- 3 Partial Off Occupancy Sensor (all answers must be Yes). For warehouses, library book stacks, corridors, stairwells in nonresidential buildings must also be accompanied by passing Test I or Test II. 4 Partial On Occupant Sensor for PAF (all answers must be Yes). 5 Occupant Sensor serving small zones for PAF (all answers must be Yes). Also must pass Test II. D. Evaluation ❑ PASS: All applicable Construction Inspection responses are complete and all applicable Equipment Testing Requirements responses are positive (Y - yes). CA Building Energy Efficiency Standards - 2016 Nonresidential Compliance April 2016 STATE OF CALIFORNIA LIGHTING CONTROL ACCEPTANCE DOCUMENT rcr_NRre_i Ti_n2_e rao.nced OAMA! CALIFORNIA ENERGY COMMISSION e CERTIFICATE OF ACCEPTANCE NRCA-LTI-02-A Lighting Control Acceptance Document (Page 5 of 5) Project Name: ♦ E forcement Age Permit Number: Doi Project Addre3g: 1 • Ciry: � w —1 ` 0 ��"' Jr��l I/Avl Zip de5� DOCUMENTATION AUTHOR'S DECLARATION STATEMENT 1. 1 certify that this Certificate of Acceptance documentation is accurate and com fete. Documentation Author Name: D(>cu&eMTatiw Author Signature: 1 Documentation hor Co pan e: Date Si ned: 1 (J Address: — \/ CEA/A fication I ntifjsajio —3 7 `�� City Phone ♦ ���� FIELD TECHNICIAN'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 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 applicable 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 Technici Signal r c M' Field Technician Company Nam ,1C.- 1 .�� _ n Position with C a (Till Address: q \ ATT Certification Id nification if phc O City/State/Zip: Phone: . llb%^ ate Signed: 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 the 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 substantiates 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 with 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 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 Certificate of Acceptance is required to be included with the documentation the builder provides to the building owner at occupancy. Responsible Ac= Pe;3 N me: Responsi a cc ptan Person Signature: i Responsible AccAnWice; om ny am Position with pan Address: --y CSLB License: `/� �1� +7 3 City/State/�,. , ^ o I� /�� DateSd: CA Building Energy Efficiency Standards - 2016 Nonresidential Compliance April 2016 STAII! OF GAuNORNIA INDOOR LIGHTING r Cr_NDrIJ TI_n1_C !P—t A n111A � I , CAt IFORNIA ENERGY COMMISSION 0 CERTIFICATE OF INSTALLATION NRCI-LTI-01-E Indoor Lighting Page 1 of 2 Project Name: 5 • :T0G6 �� n _' ^ 1 - L 7� V `v'GAN (� VItT7 _ _^ _ [� ��jlii ��j.. `j 7 d Project Address: q 1 � P`1 DE t4WI-A W V9 City: C -v -pee-_T t � O Zip Co So 1 GENERAL INFORMATION DATE OF BUILDING PERMIT: Z q 1 Lo PERMIT NUMBER: S'Q IG aO BUILDING TYPE: Nonresidential ❑ High -Rise Residential (common area) ❑ Hotel/Motel (Common Area) PHASE OF CONSTRUCTION: New Construction ❑ Addition ❑ Alteration I ❑ Unconditioned SCOPE OF RESPONSIBILITY Enter the dote of approval by enforcement agency of the Certificate of Compliance that provides the specifications for the energy efficiency measures for the scope of responsibility for this Installation Certificate. Date: D In the table below identify all applicable construction documents that specify the requirements for the scope of responsibility reported by this Installation Certificate (continued). Document Title or Description Applicable Sheets or Pages, Tables, Date Approved by Schedules, etc. Enforcement Agency Add Row Remove Last CA Building Energy Efficiency Standards - 2016 Nonresidential Compliance January 2016 STAT= OF Cr -�=ORNIA INDCGOR LIGHTING CEC-NRCI-LTI-01-E (Revised 01/16) CALIFORNIA ENERGY COMMISSION 10' CERTIFICATE OF INSTALLATION NRCI-LTI-01-E Indoor Lighting Page 2 of 2 Project Name Enfor eme�enc Par9il.Nn �0 I� s o PrW.0 Address: �� ��� City U'F�A %\�b uP u'q'5O 14, In ��►/I �rC_ U1 DOCUMENTATION AUTHOR'S DECLARATION STATEMENT 1. 1 certify that this Certificate of Installation documentation is accurate and complete. Document'tign�' lV f�(am�e:^� Documentation A or Si ure: Documentation Author Company Name : Date Signed: I Addres CEA Certification Identification (If applicable): Cit St.ip� 0 '+ l\� Phone: �� RESPONSIBLE PERSON' DECLARATION STATEMENT I certify the following under penalty of perjury, under the laws of the State of California: 1. The information provided on this Certificate of Installation is true and correct. 2. 1 am eligible under Division 3 of the Business and Professions Code in the applicable classification to accept responsibility for the system design, construction, or installation of features, materials, components, or manufactured devices for the scope of work identified on this Certificate of Installation and attest to the declarations in this statement (responsible builder/installer), otherwise I am an authorized representative of the responsible builder/installer. 3. The constructed or installed features, materials, components or manufactured devices (the installation) identified on this Certificate of Installation conforms to all applicable codes and regulations, and the installation conforms to the requirements given on the plans and specifications approved by the enforcement agency. 4. 1 reviewed a copy of the Certificate of Compliance approved by the enforcement agency that identifies the specific requirements for the scope of construction or installation identified on this Certificate of Installation, and I have ensured that the requirements that apply to the construction or installation have been met. S. I will ensure that a completed signed copy of this Certificate of Installation shall be posted, or made available with the building permit(s) issued for the building, and made available to the enforcement agency for all applicable inspections. I understand that a completed signed copy of this Certificate of Installation is required to be included with the documentation the builder provides to the building owner at occupancy. Responsible B Ider/Installer Name: VJ Responsible Bu er Inst Iler Signature: Company Name: Installing Subcontractor or General Contractor or Builder/Owner) "\ ve\f�' Position With Co pany (Title): e' bur Address: �6v� t . ,r J S� CSLB License: ,�-m� City/State/Zip., Phon Date Signed:g , 1 CA Building Energy Efficiency Standards - 2016 Nonresidential Compliance January 2016 STATE OF CALIFORNIA CONSTANT VOLUME, SINGLE ZONE, UNITARY (PACKAGED AND SPLIT) AIR CONDITIONER AND HEAT PUMP SYSTEMS CEC-NRCA-MCH-03-A (Revised 12/15) CALIFORNIA ENERGY COMMISSION CERTIFICATE OF ACCEPTANCE NRCA-MCH-03-A Constant Volume, Single Zone, Unitary (Packaged and Split) Air Conditioner and Heat Pump Systems (Page 1 of 3) Projecttime: ` ST )dSe , � In c $cf1Uz� L Enforcement Agency: Permit Number: Project Address: Io A� — � � t C� - (u city. GtI er'1itiz� Zip Code: 5� System Name or Identification/Tag; Ace $Ld 11rIt System Location or Area Served: lic Rwj �cct Note: Submit one Certificate of Acceptance for each system that mustEnforcement Agency Use: Checked by/Date demonstrate compliance. A. Construction Inspection 1. Supporting documentation needed to perform test includes, but not limited to: a. 2013 Building Energy Efficiency Standards Nonresidential Compliance Manual (NAZ5.2 Constant Volume, Single -zone, Unitary Air Conditioner and Heat Pumps Systems Acceptance At -A -Glance). b. 2013 Building Energy Efficiency Standards Manual. 2. Instrumentation to perform test includes, but not limited to: a. Temperature Meter b. Amp Meter 3. Ins Ilation (check if applies): Thermostat is located within the space -conditioning zone that is served by the HVAC system. 4. Prggramming (check all those that apply): Thermostat meets the temperature adjustment and dead band requirements of 2013 Building Energy Efficiency Standards Manual section 120.2(b). Minimum heating setpoint: L_OF. Maximum cooling setpoint 72 OF. Deadband: _�_°F. ❑ Occupied, unoccupied, and holiday schedules have been programmed per the facility's schedule. [y� Pre -occupancy purge has been programmed to meet the requirements of 2013 Building Energy Efficiency Standards Manual section 120.1(c)2. 1. Check thod used to determine pre -occupancy purge: [Lesser of: conditioned floor area times ventilation rate from 2013 Building Energy Efficiency Standards TABLE 120.1-A or 15cfm per person times the expected number of occupants. ❑ 3 complete air changes. Notes: CA Building Energy Efficiency Standards - 2013 Nonresidential Compliance Decen STATE OF CALIFORNIA CONSTANT VOLUME, SINGLE ZONE, UNITARY (PACKAGED AND SPLIT) AIR CONDITIONER AND HEAT PUMP SYSTEMS CEC-NBCA-MCH-03-A (Revised 12/151 CALIFORNIA ENERGY COMMISSION CERTIFICATE OF ACCEPTANCE NRCA-MCH-03-A Constant Volume, Single Zone, Unitary (Packaged and Split) Air Conditioner and Heat Pump Systems (Page 2 of 3) Project Name: 1 �I 5-r. 7ojC 4 o lU eir+vrt , ,SC Enforcement Agency: Permit Number: Project Address: 10 2 o N � �-�� )J W d . City: C.� �, f �� Zip Code: 416o System Name or Identification/Tag: fit) tb v"10 1 T i 1J y tt system Location or Area Served: / .1 Q O ^rI it b U 1 B. Functional Testing Requirements I Operating Modes Step 1: Disable economizer control and demand -controlled ventilation (if applicable) to prevent unexpected interactions. Occupied Mode Step 2: Heating load during occupied condition Step 3: No-load during occupied condition Indicate if Passed (P), Failed (F), or N/A (X), fill in appropriate letters Step 4: Cooling load during occupied condition Unoccupied Mode Step 5: No-load during unoccupied condition Step 6: Heating load during unoccupied condition Step 7: Cooling load during unoccupied condition Step 8: Manual override 8 7 6 5 4 3 2 Step 2 — 8: Check and verify the following for each simulation mode required a. Supply fan operates continually b. Supply fan turns off C. Supply fan cycles on and off d. System reverts to 'occupied" mode to satisfy any condition e. System turns off when manual override time period expires f. Gesfired-furrfac heat pump, r on g. No heating is provided by the unit h. No cooling is provided by the unit L Compressor stages on41 j. Outside air damper is open to minimum position I/ �- k. Outside air damper closes completely Step 9: System returned to initial operating conditions after all tests have been completed: Yes ® No Q C. Testing Results s 7 6 5 4 312 fl Indicate if Passed (P), Failed (F), or N/A (X), fill in appropriate letters D. 4valuation PASS: All Construction Inspection responses are complete and all applicable Testing Results responses are "Pass" (P) CA Building Energy Efficiency Standards - 2013 Nonresidential Compliance December 2015 STATE OF CALIFORNIA CONSTANT VOLUME, SINGLE ZONE, UNITARY (PACKAGED AND SPLIT) AIR CONDITIONER AND HEAT PUMP SYSTEMS CEC-NRCA_MCH-03 A tReviced 1211-51 CALIFORNIA ENERGY COMMISSION CERTIFICATE OF ACCEPTANCE NRCA-MCH-03-A Constant Volume, Single Zone, Unitary (Packaged and Split) Air Conditioner and Heat Pump Systems (Page 3 of 3) Project Name: 1 Cue 1 Enforcement Agency: Permit Number: � IN' �c �"(` ATT Certification Identification (If applicable): City/State/Zip: Project Address: 0i t,'. ) e -A- A co: CL) C 2 Zip Code: 1 RSoI�( System Name pr Identificatio ag: r ' � System tan or Area Served: /,tivC 0 z �', 1 VL f, DOCUMENTATION AUTHOR'S DECLARATION STATEMENT 1. 1 certify that this Certificate of Acceptance documentation is accurate and complete. Documentation Author Name: Documentation Author Signature: Documentation Author Company Name: Date Signed: Address: ATT Certification Identification (If applicable): City/State/Zip: Phone: FIELD TECHNICIAN'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 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 applicable 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: �S c` Field h ci gna r Fieo Technicianf p ylame: P ' ' n with C m an (Title): E 7X /Y'6 I I N S �V iCE 114 � Address: A Certification Identification (if applicable): o I S� iTe fiIVIE D Ci /St /Zip: A z� Phone: i 3a I�E0�1 Dat Signe 3`f� 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 the 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 substantiates 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 with 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 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 Certificate of Acceptance is required to be included with thec men n the builder provides to the building owner at occupancy. Sponsi'ble Acte nce Person Name: Respons' Ac ptan rson Signature: i J EN R onsible Acce nc Person C mpany Name: Position wit mp (Title): Yin I 31 I e)' 7 Address:�(( CSB License: [CiKstate/z'p: �� �Z3 Phone: `� ,C) Dat Sjgned: 2oi CA Building Energy Efficiency Standards - 2013 Nonresidential Compliance December 2015 CERTIFICATE OF ACCEPTANCE NRCA-MCH-02-A NA7.5.1 Outdoor Air Acceptance (Page 1 of 3) Enforcement Agency: Permit Number: Note: Submit one Certificate of Acceptance for each systemI Enforcement Agency Use: Checked by/Date that must demonstrate compliance. Documentation Author's Declaration Statement • 1 certify that this Certificate of Acceptance documentation is accurate and conliwie. Name: So iJ ��Zti Signatur . Company rMem ( N �' Date: 23 201( If Appli able ]Address: i q0 I I � Ilk � � c� S� ifs A ❑ CEA or ❑ CEPE (Certification #): City/ t te/ i : G Phone: ' G -I FIELD TECHNICIAN'S 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 the person who performed the acceptance requirements verification reported on this Certificate of Acceptance (Field Technician). • 1 certify that the construction/installation identified on this form 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. • I have confirmed that the Installation Certificate(s) for the construction/installation identified on this form has been completed and is posted or made available with the building permit(s) issued for the building. Com any N me: Irv\ R - Field Technici n's Na Field Techni pan's Signature: 0.6 3011 Responsible Person's N19e: Date Signed: Position With Compan (Title): RESPONSIBLE PERSON'S DECLARATION STATEMENT • 1 certify under penalty of perjury, under the laws of the State of California, that I am the Field Technician, or the Field Technician is acting on my behalf as my employee or my agent and 1 have reviewed the information provided on this form. • 1 am a licensed contractor, architect, or engineer, who is eligible under Division 3 of the Business and Professions Code, in the applicable classification, to take responsibility for the scope of work specified on this document and attest to the declarations in this statement (responsible person). • 1 certify that the information provided on this form substantiates that the construction/installation identified on this form 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. • 1 have confirmed that the Installation Certificate(s) for the construction/installation identified on this form has been completed and is posted or made available with the building permit(s) issued for the building. • 1 will ensure that a completed, signed copy of this Certificate of Acceptance 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 Certificate of Acceptance is required to be included with the documentation the builder provides to the building owner at occupancy. ame: CompaLXT-4w Phone: C w- 0.6 3011 Responsible Person's N19e: Responsible son's n ure: --Z License: Date Signe : P ith �o_, ny (Titl : 2 3 2� (� r j CERTIFICATE OF ACCEPTANCE NRCA-MCH-02-A NA7.5.1 Outdoor Air Acceptance (Page 2 of 3) Verify measured outside airflow reading is within + 10% of the total required outside airflow. Intent: Reference MECH-3C (Column H or Column 1) or Mechanical Equipment Schedules. Construction Inspection Note: MCH -2A can be performed in conjunction with MCH -7A Supply Fan VFD Acceptance (if applicable) since testing activities 1. Supporting documentation needed to perform test includes: a. As -built and/or design documents (Mechanical Equipment Schedules). b. 2013 Building Energy Efficiency Standards Nonresidential Compliance Manual (NA7.5.1.1 Ventilation Systems: Variable Air Systems At -A -Glance and NA7.5.1.2 Constant Volume Systems Outdoor Air Acceptance At -A -Glance). C. 2013 Building Energy Efficiency Standards. 2. Instrumentation needed to perform test includes: a. Watch b. Calibrated means to measure airflow (i.e. hot-wire anemometer, velocity pressure probe, etc.). 1. Method and equipment used: 2. Equipment calibration date (must be within one year):, 3. System type (check either VAV or CAV): ❑ VAV Q CAV ❑ Check if Variable Air Volume (VAV) and complete the following: a. Outdoor airflow sensor (check one that applies): ❑ Sensor used to control outdoor air flow is either factory calibrated or field calibrated. ❑ Check if factory calibrated and attach calibration certification. ❑ Check if field calibrated and attach calibration results. b. Damper Control (must be checked): ❑ Dynamic damper control is being used to control outside air. (This is NOT a fixed minimum position). C. One of the following dynamic controls is being utilized to control outside air (check method used) ❑ Dual Minimum Setpoint Design ❑ Energy Balance Method ❑ Return Fan Tracking ❑ Airflow Measurement of the Entire Outdoor Air Inlet ❑ Injection Fan Method ❑ Dedicated Minimum Ventilation Damper with Pressure Control ❑ Other Active Control, Describe: Check if Constant Air Volume (CAV) and verify the following: ❑ System is designed to provide a fixed minimum OSA when the unit is on. 4. Method of delivering outside air to the unit (check one of the following): ❑ Outside air is ducted to the return air plenum. a. Confirm that outside air is ducted to either (check one of the following): ❑ Within five ft. of the unit. Within 15 ft. of the unit, with the air directed substantially toward the unit, and with a discharge velocity of ❑ at least 500 ft. per minute. p' Return air plenum is NOT used to distribute outside air to the unit. Le. outside air is ducted directly to the unit or outside air is provided independent of the unit. 5. Pre -occupancy purge has been programmed for the 1 -hour period immediately before the building is normally occupied to provide (one of the following methods must be verified and checked): The conditioned floor area times the ventilation rate from the 2013 Building Energy Efficiency Standards TABLE 121-A, or 15 cfm per person times the expected number of occupants, whichever is less. CERTIFICATE OF ACCEPTANCE NRCA-MCH-02-A NA7.5.1 Outdoor Air Acceptance (Page 3 of 3) I❑ 3 complete air changes to the zone served by the air handler. I NA7.5.1.1 Outdoor Air Acceptance N A. Functional Testing (Check appropriate column) ❑ CAV O AV Step 1: Verify unit is not in economizer mode during test (economizer disabled). Q' ❑ Note: Shaded boxes do not apply for CAV systems c. Outside air damper position stabilizes within 5 minutes (Step 2d < 5 minutes) Step 2: CAV and VAV testing at full supply airflow Determine Percent Outside Air at reduced supply airflow (%OARA) for Step 3 (VAV only) a Adjust supply air to achieve design airflow or maximum airflow at a' full cooling. Record VFD speed (Hz). Hz b. Measured outdoor airflow reading (cfm) cfm cfm Required outdoor airflow (cfm) (from MECH-3C, Column 1, or C. Mechanical Equipment Schedules). y g cfm cfm Time for outside air damper to stabilize after full supply airflow is achieved d' (minutes): Y N min Step 3: VAV testing at reduced supply airflow CAV V V a. Adjust supply airflow to either the sum of the minimum zone airflows, full heating, or 30% of the total design airflow. Record VFD speed (Hz). Hz b. Measured outdoor airflow reading (cfm) cfm C. Required outdoor airflow (cfm) (from MECH-3C, Column i, or mechanical equipment schedules). cfm d. Time for outside air damper to stabilize after reduced supply airflow is achieved (minutes): min Step 4: Return to initial conditions (check) B. Testing Calculations & Results Determine Percent Outside Air at full supply airflow (%OAFA) for Step 2 a. %OAFA = Measured outdoor airflow reading /Required outdoor airflow (Step2b/Step2c) ! I % % b. %OAFA is within 10% of design Outside Air. (90%<_ %OAFA <_ 110%) N Y / c. Outside air damper position stabilizes within 5 minutes (Step 2d < 5 minutes) Y / Determine Percent Outside Air at reduced supply airflow (%OARA) for Step 3 (VAV only) a %OARA = Measured outdoor airflow reading /Required outdoor airflow reading (Step3b/Step3c) b. %OARA is within 10% of design Outside Air. (90%:5 %OARA <_ 110%) Y N C. Outside air damper position stabilizes within 5 minutes (Step 3d < 5 minutes) Y N Note: The intent of this test is to ensure that 1) all air handlers provide the minimum amount of OSA and 2) VAV air handlers use dynamic controls to avoid over ventilation. C. � Evaluation : �( PASS: All Construction Inspection responses are complete and Testing Calculations & Results responses are positive (Y - yes) \/f 'S CERTIFICATE of INSTALLATION (Part 1 of 2) NRCI-ENV-01-E PROJECT NAME: Nt ru 'Tv-1V/Z1NI S11 )CSO'►+ of 0 C,f1'0C 5O",t OFeia gV11P,w6 DATE: I?- Zfi, Date Approved By the Enforcement Agency Building Permit PROJECT ' G ADDRESS: rJp . %o0 /U & 60 Chocked/sate Agency Enforcement A Use GENERAL INFORMATION DATE OF BUILDING PERMMIT PERMIT # BUILDING TYPE Ef Nonresidential ❑ High -Rise Residential ❑ Hotel/Motel Guest Room PHASE OF CONSTRUCTION New Construction ❑Addition 11 Alteration ❑Unconditioned If more than one person has responsibilityfor building construction, each person shall prepare and sign an Installation Certificate document applicable to the portion of construction for which they are responsible; alternatively, the person with chief responsibilityfor construction shall prepare and sign the Installation Certificate document(s) for the entire construction. 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 (responsible person). • I certify that the installed features, materials, components, or manufactured devices identified on this certificate (the installation) conforms to all applicable codes and regulations, and the installation is consistent with the plans and specifications approved by the enforcement agency. • I reviewed a copy of the Certificate of Compliance approved by the enforcement agency that identifies the specific requirements for the installation. I certify that the requirements detailed on the Certificate of Compliance that apply to the installation 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: �( A buC- Responsible Person' Name: Respo e e Signature: Date Approved By the Enforcement Agency Lic.# Datta Signo: Position With C pan I SCOPE OF RESPONSIBILITY Enter the date of approval by enforcement agency of the Certificate of Compliance that provides Date: the specifications for the energy efficiency measures for the scope of responsibilityfor this f l� /2,1 l4 Installation Certificate: l In the table below identify all applicable construction documents that specify the requirements for the scope of responsibility for this Installation Certificate. Document Title or Description Applicable Sheets or Pages, Tables, Schedules, etc. Date Approved By the Enforcement Agency 2013 Nonresidential Compliance Forms February 2013 CERTIFICATE of INSTALLATION (Part 2 of 2) NRCI-ENV-01- In the table below idents all applicable construction documents that speck the requirements for the scope of responsibility reported by this Installation Certificate (continued). Date Approved By Document Title or Description Applicable Sheets or Pages, Tables, Schedules, etc. the Enforcement 2013 Nonresidential Compliance Forms February 2013 CERTIFICATE of INSTALLATION (Part 1 of 2) NRCI-MCH-01-E PROTECT NAME: �J e�,y 1 Ln� DATE: r r1 ST f, 1 — I" Zo Respon ' Pe Signatur , ✓ U > C G' ` iJ e, V`, c _ C C O ITI[t f) 4s�c o 1 Building Pemut P�R) OJJECT ADDRESS: f� I C A n C Checked by/Agency " ll 1 r'_,0 �1 Enforcement A c Use GENERAL INFORMATION DATE OF BUILDING PERMIT I PERMIT # BUILDING TYPE ONonresidential ❑ High -Rise Residential ❑ Hotel/Motel Guest Room PHASE OF New Construction 11 Addition ❑Alteration ❑Unconditioned CONSTRUCTION If more than one person has responsibilityfor building construction, each person shall prepare and sign an Installation Certificate document applicable to the portion of construction for which they are responsible; alternatively, the person with chief responsibilityfor construction shall prepare and sign the Installation Certificate documents) for the entire construction. 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 (responsible person). • I certify that the installed features, materials, components, or manufactured devices identified on this certificate (the installation) conforms to all applicable codes and regulations, and the installation is consistent with the plans and specifications approved by the enforcement agency. • I reviewed a copy of the Certificate of Compliance approved by the enforcement agency that identifies the specific requirements for the installation. I certify that the requirements detailed on the Certificate of Compliance that apply to the installation 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: br,�c-(_ AR NL /, Res 7o�n/s�ible Person's Name: Respon ' Pe Signatur Date Approved By the Enforcement Agency Lic.# Date Signe Position With Compa U 7 VL i NC -3, ) ojT SCOPE OF RESPONSIBILITY Enter the date of approval by enforcement agency of the Certificate of Compliance that provides Date - the specifications for the energy efficiency measures for the scope of responsibilityfor this 71/ I Installation Certificate: `� In the table below identify all applicable construction documents that specify the requirements for the scope of responsibility for this Installation Certificate. Document Title or Description Applicable Sheets or Pages, Tables, Schedules, etc. Date Approved By the Enforcement Agency 2013 Nonresidential Compliance Forms February 2013 I CERTIFICATE of INSTALLATION (Part 2 of 2) NRCI-MCH-01-E I In the table below identify all applicable construction documents that speck the requirements for the scope of responsibility reported by this Installation Certificate (continued). Date Approved By Document Title or Description Applicable Sheets or Pages, Tables, Schedules, etc. the Enforcement 2013 Nonresidential Compliance Forms February 2013 COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • r-,! I -In rx'a CUPERTINO ❑ REQUEST FOR MODIFICATION OF CODE (CBC 104.10, CFC 104.8) ❑x REQUEST FOR ALTERNATE MATERIAL, DESIGN OR METHOD OF CONSTRUCTION (CBC 104.11, CFC 104.9) ❑ REQUEST FOR HARDSHIP EXEMPTION OR EQUIVALENT FACILITATION (HEALTH AND SAFETY CODE 19957) Tr) annly fnr thic rani iact r.e)n to sactinns 1 9 R 3 (ink nr tvna) SITE ADDRESS 10120 N. DeAnza Blvd, Cupertino, CA APN 316-26-097 DATE 02/05/2016 St Joseph of Cupertino School Owner............................................................................................................................ PC #: Type: VB Construction Address, rtino, CA 15050017 1 ...10120.........N......DeAnza..............Blvd...........Cupe.......... Permit #: ............. Stories:................................. Email..michael.lee.@sj.cs.c.h.00l.o.r.g ............... Phone.(408)210-2019 .......................... ...................................................PLN 711 E " #:.................................. Dept./Div.. Building Div Occupancy: Floor Area:. 420 s.f. David A. HuboiArchitect Applicant................................................................. Title ............................................... 601 McCra St Suite 202 Address.......................................................................................................................... Job Status: ........................... Occ. Load: .16 831 636-0949 ............................... Phone. ...... .............. . Email Hu �� S 1 '�. `!.....'1."1.................Date:....-.1.....I.�!.... Use of Bld Office / Tutoring g . .. • . . 2 1REQUEST: For code modifications, please state the applicable code requirement and the extent of relief desired. For alternate requests, state the type of system proposed and design methods. Submit plans if necessary to illustrate request. Additional sheets or data may be attached. an existing 24,748 s.f. type V -B E-Occupancyschool. The new total area of the building school is 25,168 s.f. The maximum allowable floor area for a 1 -story, Type V -B, E-Occupancybuilding is 9,500 S.f. 3 JUSTIFICATION/FINDINGS OF EQUIVALENCY: For code modifications, applicant shall demonstrate that special, individual reasons exist that make compliance with the strict letter of the ordinance impractical and that equivalency is provided. For alternate requests, applicant shall demonstrate suitability, strength, effectiveness, fire resistance, durability, safety and sanitation that is equivalent to the code for a similar use. Code Section(s): Attach additional sheets if necessary. Tin prinvide firp -,Pj).qrqt*nn as -,bnwn Inn the attarhed exhibit (partial plat plan) Petitioner's - ............... Signature:....... I ...... Position:....Architect................. Date: Rev' By: B :.... ......................................Date:...�t....E7..... The Request is: 01GRANTED ❑ DENIED I Dept. Comments: CONDITIONS OF APPROVAL: TPfAO " No. of Items:.........! ................... Fee Due: $................................ Date Paid: Receipt No.: .............................. Processed by: ............................ CD r jC 5 CIV Building Official:... .. ry /...... ..................... Print:...(..1. `�I'/ S 1 '�. `!.....'1."1.................Date:....-.1.....I.�!.... FireMarshal: ................................................ .. I .................................. Print:................................................................................. Date:... ...... ............. 0............ utrAK t MtN t Ac t IUN: Atter determination, copies to: i) applicant, z) permit rue Altjorm_2015.doc revised 07/01/15 AREA OF EXISTING WALL ADJACENT TO IMAGINARY PROPERTY LINE = 57G 5Q.FT.; ONE (1) 4'-2" x4'-4" WINDOW TO REMAIN 16.5 5Q.FT. = 0.OG% OF WALL AREA EXISTING BUILDING (ADMINISTRATION) (E) 4'-2" x 4'-4" REMOVE (E) 6 WINDOWS * WINDOW TO REMAIN CA5E IN OPENINGS: RETROFIT A5 REQ'D. TO TRAN51FORM TO - (E) GLU-LAM I -hR. FIRE -RATED WALL; SEE BEAM DETAIL #3 @ SHEET AO.50 PORTION OF (E) ROOF —OVERIIANG_TO_RE_MAIN — �_ ` IMAGINARY - PROPERTY LINE - N 3 -- EDGE OF BREEZEWAY EXI5TING PLANTER F l - REMOVE (E) COLUMNS } V REMOVE PORTION OF EXISTING INDICATES I -NR FIRE -RATED ¢ STUCCO SOFFIT BREEZEWAY WALL A5 PER 2013 CBC TABLE 722.2.1.4(2); SEE DETAIL z w Q p w DA73�50 L IMAGINARY PROPERTY LINE _ ". (E) I -HR -,_./ (E) DOOR RATED CMU TO REMAIN ----' EXISTING BUILDING (RESTROOM5) REMOVE (E) DOOR d PROVIDE I -MR. FIRE -RATED INFILL; U5E --- PTDF IN CONTACT W/ MASONRY; SEE DETAIL A 50 % //��� - 0-0" EX15TING (5'-0" GOURTYARD MIN.) y. EXITING NOTE: ONLY ONE (I) DOOR IS REQ'D FOR EXITING A5 EXI5TING SPACE 15 A RESTROOM W/ LESS THAN 50 OCCUPANTS. (N) T5 (M 4x12 DF#I EDGE BEAM PORTION OF O BREEZEWAY �� TO REMAIN (M T5 EDTY,. PARTIAL PLOT PLAN NOTI7MSCALE