14100064-CALGREEN CFang's
N�`FGNATURE DECLARATIONS
nceProject Name:ProjectAddresewS uare, Cupertino, CA
Project Descripft addition CEO W
SECTION 1 — DESIGN VERIFICATION
Complete all lines of Section 1 —"Design Verification" and submit the completed checklist (Columns 1 and 2)with the
plans and building permit application to the Building Department.
The owner and design professional responsible for compliance with CalGreen Standards have revised the plans and
certify that the items checked above are hereby incorporated into the project plans and will be implemented into the
project in accordance with the requirements set forth in the 2013 California Green Building Standards Code as
adopted by the City of Cupertino.
10/07/2014
Owner's �arng
ature Date
Xiang
Owned Na e Print)
10/07/2014
Design Professional's Signature Date
Michael Tsao
Z
Prof ssi s Name (Please Print)
E 10/07/2014
Signature of License Professional responsible for CalGreen compliance Date
Michael Tsao 650-676-7882
Name of License Professional responsible for CalGreen compliance(Please Print) Phone
miketsao@hotmail.com
Email Address for License Professional responsible for CalGreen compliance
SECTION 2 — IMPLEMENTATION VERIFICATION
Complete, sign and submit the competed checklist, including column 3, together with all original signatures on Section
2 to the Building Department prior to Building Department final inspection.
I have inspected the work and have received sufficient documentation to verify and certify that the project identified
above was constructed in accordance with this Green Building Checklist and in accordance with the requirements of
the 2013 Qalifort3ieQ a Building Standards Code as adopted by the City of Cupertino.
Signature oficense Professional responsible for CalGreen compliance Date
Name of License Professional�XW-1�
ble for CalGreen compliance (Please Print) Phone
44.11-CG�sl ow � CON k
Email Address for License Professional responsible for CalGreen compliance
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