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15080109CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10971 N WOLFE RD CONTRACTOR:, PERMIT NO: 15080109 � vt-C S ` (- ✓� E e c3 OWNER'S NAME: CUPERTINO VILLAGE LP DATE ISSUED: 10/06/2015 OWNER'S PHONE: 4083166782 PHONE NO: 7A LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑ License CIS -6 TOFU PLUS - T.I. TO RENOVATE/RECONFIGURE (E) Class Lic. # 7 0 Z RESTAURANT (2,866 S.F.)-TI PREP 15090133 ap Contractor p b JC ?� i'c� KDate I hereby affirm that I am licensed under 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: Sq. Ft Floor Area: Valuation: $100000 1 Ive and will maintain a certificate of consent to self -insure for Worker's Zipensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. APN Number: 31605051.10971 Occupancy Type: 2. 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. PERMIT EXPIRES IF WORK IS NOT STARTED APPLICANT CERTIFICATION WITHIN 180 DAYS OF PERMIT ISSUANCE OR I certify that I have read this application and state that the above information is 180 DAY LLED INSPECTION. 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 ssued b Date 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 sour egulations er the upertino Municipal Code, Section 9.18. RE -ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is Signature Date /11 ` `P –f installed without first obtaining an inspection, I agree to remove all new materials for 17 inspection. Signature of Applicant: Date: OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER the following two reasons: i. 1, 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 HAZARDOUS MATERIALS DISCLOSURE sale (Sec.7044, Business & Professions Code) I have read the hazardous materials requirements under Chapter 6.95 of the 2. I, as owner of the property, am exclusively contracting with licensed contractors to California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain construct the project (Sec.7044, Business & Professions Code). compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. I hereby affirm under penalty of perjury one of the following three declarations: Additionally, should I use equipment or devices which emit hazardous air 1. I have and will maintain a Certificate of Consent to self -insure for Worker's contaminants as defined by the Bay Area Air Quality Management District I will Compensation, as provided for by Section 3700 of the Labor Code, for the maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the performance of the work for which this permit is issued. Health & Safety Code, Sections 25505, 25533, and 25534. 2. I have and will maintain Worker's Compensation Insurance, as provided for by Own or autho ' ed n p Section 3700 of the Labor Code, for the performance of the work for which this Date: �� `—( permit is issued. 3. I certify that in the performance of the work for which this permit is issued, I shall CONSTRUCTION LENDING AGENCY not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If, after making this certificate of exemption, I I hereby affirm that there is a construction lending agency for the performance of work's become subject to the Worker's Compensation provisions of the Labor Code, I for which this permit is issued (Sec. 3097, Civ C.) Lender's Name must forthwith comply with such provisions or this permit shall be deemed revoked. Lender's Address APPLICANT CERTIFICATION ARCHITECT'S DECLARATION I certify that I have read this application and state that the above information is I understand my plans shall be used as public records. 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 Licensed Professional upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature Date -Y CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 771-3228 FAX (408) 777-3333 buildingacupertino ora :1 N.hWW c0] iS T1-cUU,'MON ❑ ADD; rION ALTERATION / TI ❑ REVISION /DEFERRED ORIGINAL PERMIT # PROJLC r ADDRESS ®` i _ APN # OWNER NAMEU6 �- PHONE tip s.7Ygp ry E-MAIL leeyp 1, 11 K STREErADDRES5 /J ,w. f , .�f /� _% CITY, STATE;ZiP .� Fpa{ ` CON'IAcT NAME 1tM L7j1("(� PHON .�,p vii MAI E L. 0 �i/l STREET ADDRESS CITY. S'L'ATE, ZIP 1 FAY 0 ❑-OWNER ❑ OWNER -BUILDER ❑ OWNERAGENT. ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHn ECTENGINEER - E3 DEVELOPER 13 TENANT ...••• CONTRA CTORNAME'-I LICENSE NUMBER^ LICENSE TYPE BUS. LIC COMPANYNAME E-MAIL FAX STREET ADDRESS - CITY, STATE. ZIP PHONE ARCH TECTlENGINELF N1�MEFic ENSE NUyLBER BUS. LIC # COMPANY NAME .L F-MAILq� g/ ,�j� FAX i0L yt4 STREET ADDRESSPox q � 1 % 71 CITY, STATE, ZIP ®� ) ( PiiONEeA$ .2 ®p ®yQ 7fA9 DESCRIPTION OF WORK ►n.6t,h.� 1 l�i�'Url�-S � �^ fS� k`1 -2-L��o� r. EXISTING USE. >� PROPOSED USE _ CONSTR. �p K —1 TY E " It STORIES USE TYPE OCC. SQ.FT. VALUATION{$) EXIT AREA �.(, v NEW FLOOR, AREA DEMO AREA TOTAL NET AREA BATHROOM KITCHEN REMODEL AREA "' REMODEL AREA OTHER REMODEL AREA e4'6 PORC977 D ,AREA TOTAL DECK/PORCH AREA GARAGE AREA:DFTACH P.TTACII 8 DWELLING UNITS: IS A SECOND UNIT - ❑ YES SECOND STORY 171'ES - SEINGADDED? O ADDITION?f0 r -❑3 PRE -APPLICATION ❑'iT:S IF YES, PROVIDE COPY OOFFq PLANNING APPL # JZNO PLANNING APPROVAL LETTER IS TLIE BLDG AN YESR EICHLER HOME' ;WO - L VALUATION: (� hele'W.:f c rt±f}, to each of the following: I am the property owner or aut orized agent to the pr . owner's behalf. I have read this application and the information I have provided is correct. I have read the Description of }York and veffy it is I agree to comply with all applicable local ordinances and stat, laws relating to buil ' z o [ruction. I. authorize representatives of Cupertino to ent above -identified property for inspection purposes. Signature ofApplicarlt/P.gent: Date: SUPPLEMENTAL INFORMMATION REQUIRED New SFD or Muhifamily dwellings: Apply for demolition permit for . - NINEt existing buildings f. Demolition permit is required prior to issuance of building g permit for new building. Cotmnerclai Bides: Provide a completed Hazardous Materials Disclosure t ei form if any Hazardous Materials are being used as part of this project. RIM _ Copy of Planning Approval Letter or Meeting with Planning prior to of Building Permit application. submittal BldgApp_2011.doe revised 06121/11 CITY OF CUPERTINO FVF. F.CTlMATnI2 _ RTTH 71TN!' ilrvrcrnxT ADDRESS: 10971 N WOLFE RD DATE: 08/13/2015 REVIEWED BY: MELISSA PC FEES APN: 316 05 051 BP#: 15080109 BP FEE ID VALUATION: j$100,000 II-B,iI1-B,IV,V-B 2,866 $2,551.36 IATIPLNCK $1,613.28 PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement PRIMARY Commercial Building PENTAMATION Permit Fee: PERMIT TYPE: 1A TI WORK TOFU PLUS - T.I. TO RENOVATE/RECONFIGURE E A-2 (2,866 S.F. SCOPE OCCUPANCY TYPE: TYPE OF CONSTR.. FLR AREA sJ. PC FEES PC FEE ID BP FEES BP FEE ID A (Tenant Improvements) II-B,iI1-B,IV,V-B 2,866 $2,551.36 IATIPLNCK $1,613.28 1,4TIINSP PME Plan Check: $0.00 Permit Fee: $1,613.28 Suppl. Insp. Feer Reg. 0 OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Tav: TOTALS: 2,866 $2,551.36 `x $1,613.28 Oiller -I*zch InsP, Pf{wt h. Plan 'he,'A" 'lumb. Permit T *ec: 011, r phurill3 Insn i -loci,. f'?rtr7r?. Izry ". Fee: NOTE: This estimate does not include fees due to other Departments (i.e. /e€.'.PPan Cbe'cl{ Elec. Perini? FEe: Other A-lec. Imp. Eke. Insp, Fee: Works, Fire, Sanitary Sewer District, School District etr_L_ %hese faoc nra hacarf nn !ho ..:.,.1 __ --/,, ..., sb- n--# f- / d,f FEE ITEMS (Tee Resolution 11-0531 . 711113) FEE QTY/FEE MISC ITEMS Plan Check Fee: $2,551.36 Select a Mise Bldg/Structure or Element of a Building Reg. 0 OT Suppl. PC Fee: (j)0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $1,613.28 Suppl. Insp. Feer Reg. 0 OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Tav: E) Work Without Permit? 0 Yes No $0.00 Advanced Planning Feer $0.00 Select a Non -Residential Building or Structure 0 A IrUt l Fees: Strong Motion Fee: 1BSEISNIICO $28.00 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $4.00 SUBTOTAL: $4,196.64 $0.00 TOTAIL F>uE< ' $4,196.64 Revised: 07/02/2015 CUPERTINO CONTRACTOR % SUBCONTRACTOR LIST { Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 Fax: 408-777-3333 I JOBADDRESS: /0.9%/ n/ !.✓o/ e PERMIT# 45-041 O/Og OWNER'S NAME: PHONE # GENERAL CONTRAC OR: Co v. c" •, c r, v: (A BUSINESS LICENSE # ADDRESS:5 auL1 {# CITY/ZIPCODE: o�►� ��^ Vim) *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 # Cement Finishing Electrical EN €. C 0 o 4z -T NOX-4 5519 Excavation Fencing Flooring / Carpeting Linoleum / Wood Glass / Glazing Heating Goal �� C'OV'4 61 34 6 n`[ Insulation a g2R1 gq- Landscaping Lathing Masonry Painting / Wallpaper Paving Plastering Plumbing uvr. in t 6 T g' SS f Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner / Contractor Signature /.- Date ��r 'HAZARDOUS MATERIAL,81 CHECKLIST COMMUNITY DEVELOPMENT, DEPARTMENT • BUILDING DIVISION ALBERT SALVADOR, P.E C.B.O.1 BUILDING OFFICIAL 1000 TORRE AVENUE- - COPERTINO, CA 95014-3255 408) 777:32281 -. -;F (4,08) 777-3333 buildinc le,cupertino.org -si 61iI6 delay's'�uld result for the Fire Department plan review, please complete the ! I , ,. ist determine if�an additional level of Hazard ous,Materials plan review will be THE P'ROOO ED SCOPE OF WORK INCLUDE ANY OF THE'FOLLOWING'?, it PLEASE MARK YOUR ANSWER WITH AN ',X' THE YES NO SOX ON THE SIDE YES INO 1, w i,. MELOVV.'- 'dispensing; mixing or storage of flammable or combustible liquids or gases, h rd dslmatehalsetc, t'lcuwrimc) a,& "t r back-up rooms or racks. y !PURP03E',,! Propane 11. etanks.; o minimize 13 i!iTJ 11-7 i1611owing! cher req6'ired.! la, .:l 14. Gasolind stations With underground tanks.' MARKI 'YES: 'HAZARDOUS MATERIAL,81 CHECKLIST COMMUNITY DEVELOPMENT, DEPARTMENT • BUILDING DIVISION ALBERT SALVADOR, P.E C.B.O.1 BUILDING OFFICIAL 1000 TORRE AVENUE- - COPERTINO, CA 95014-3255 408) 777:32281 -. -;F (4,08) 777-3333 buildinc le,cupertino.org -si 61iI6 delay's'�uld result for the Fire Department plan review, please complete the ! I , ,. ist determine if�an additional level of Hazard ous,Materials plan review will be THE P'ROOO ED SCOPE OF WORK INCLUDE ANY OF THE'FOLLOWING'?, it PLEASE MARK YOUR ANSWER WITH AN ',X' THE YES NO SOX ON THE SIDE YES INO 1, w i,. MELOVV.'- 'dispensing; mixing or storage of flammable or combustible liquids or gases, h rd dslmatehalsetc, a,& "t r back-up rooms or racks. y Propane 11. etanks.; 11-7 .:l 14. Gasolind stations With underground tanks.' i5. j16sjajlat6h'Io'r re' lilac'eirrie'nfabove ground or underground storage,of liquid petroleum petroleum ucts liquefied gases,,compressed natural. gas, explosives or other 'Oulated hiazardods mat6ria19.'--,' 16. Gasroorr for dentist, doctors'6r veterinarians., 7. 66"Ine!r! altijrs with back-up diesel'or other fu6ls.'' 8. r6f,riclie ration systems '9 Fuel cell -stems. 11 ir lj 0. (Commercial pool systems,:, :,11 al ;Storage areas. hemG",- 12.',FIammablj-,- liquid storage. ss'eid Gases. 113..'Compressed pre 4. 'Dry cleaners. ners. i: ;15.:;PrintShbps. 16. ;'At.itol 'R'e"'� lir and Auto Body Shops. ..p 7.,:Research taind.Development. %( ' jFor any diti1ad",.)nal information regarding this ch ecklist, please contact Hazardous Materials Specialist, Santa ,'bara County Fi re Department; at (408) 378-4010.' HasMal 2011.doc revised 03107111 PERMIT SET 07 FILE STATE OF CALIFORNIA INDOOR LIGHTING CEC-NRCC-LTI-01-E (Revised 08/15) CALIFORNIA ENERGY COMMISSION CERTIFICATE OF COMPLIANCE NRCC-LTI-01-E Indoor Lighting (Page 1 of 6) Project Name: TvT ��,C,r `r— �r L: / Ty )C Date Prepared: A. General Information For detailed instructions on the use of this and all Energy Efficiency Standards compliance documents, refer to the Nonresidential Manual published by the California Energy Commission. YES NO FORM TITLE NRCC-LTI-01-E Certificate of Compliance. All Pages required on plans for all submittals. NRCC-LTi-02-E Climate Zone: Conditioned Floor Area : 1� Indoor Lighting Power Allowance NRCC-LTI-04-E Tailored Method Worksheets NRCC-LTI-OS-E I Line Voltage Track Lighting Worksheets Unconditioned Floor Area Building Type: Nonresidential ❑ High -Rise Residential ❑ Hotel/Motel ❑ Schools ❑ Relocatable Public Schools V Conditioned Spaces ❑ Unconditioned Spaces Phase of Construction: ❑ New Construction ❑ Addition A Alteration Method of Compliance: ❑ Complete Building Area Category ❑ Tailored Project Address: 10-771 1 V 1'70,2p --4 �o/ B. Lighting Compliance Documents (select yes for each document included) For detailed instructions on the use of this and all Energy Efficiency Standards compliance documents, refer to the Nonresidential Manual published by the California Energy Commission. YES NO FORM TITLE NRCC-LTI-01-E Certificate of Compliance. All Pages required on plans for all submittals. NRCC-LTi-02-E Lighting Controls, Certificate of Compliance, and PAF Calculation. All Pages required on plans for all submittals. NRCC-LTI-03-E Indoor Lighting Power Allowance NRCC-LTI-04-E Tailored Method Worksheets NRCC-LTI-OS-E I Line Voltage Track Lighting Worksheets CA Building Energy Efficiency Standards - 2013 Nonresidential Compliance August 2015 STATE OF CALIFORNIA INDOOR LIGHTING rol CEC-NRCC-LTI-01-E (Revised 08/15) CALIFORNIA ENERGY COMMISSION CERTIFICATE OF COMPLIANCE NRCC-LTI-01-E Indoor Lighting (Page 2 of 6) Project Name: Date Prepared: C. Summary of Allowed Lighting Power Conditioned and Unconditioned space Lighting must not be combined for compliance Indoor Lighting Power for Conditioned Spaces Indoor Lighting Power for Unconditioned Spaces Form/Title J Watts Watts ❑ Field Inspector Installed Lighting Installed Lighting NRCI-LTI-02-E - Must be submitted for a lighting control system, or for an Energy Management Control System (EMCS), q 1. NRCC-LTI-01-E, page 4 + NRCC-LTI-01-E, page 4 + 2. PORTABLE ONLY FOR OFFICES + / V NRCI-LTI-04-E - Must be submitted for two interlocked systems serving an auditorium, a convention center, a NRCC-LTI-01-E, page 3 (] conference room, a multipurpose room, or a theater to be recognized for compliance. 3 Minus Lighting Control Credits �/T Minus Lighting Control Credits V! / NRCI-LTI-06-E - Must be submitted for additional wattage installed in a video conferencing studio to be recognized for NRCC-LTI-02-E, page 2 NRCC-LTI-02-E, page 2 � 4. Adjusted Installed Lighting Power Adjusted Installed Lighting Power (row 1 plus row 2 minus row 3) (row 1 minus row 3) 5. Complies ONLY if Installed <_ Allowed Complies ONLY if Installed <_ Allowed 6' Allowed Lighting Power Allowed Lighting Power Conditioned NRCC-LTI-03-E, page 1 Unconditioned NRCC-LTI-03-E, page 1 D. Declaration of Required Installation Certificates Declare by selecting yes for all Installation Certificates that will be submitted. (Retain copies and verify forms are completed and signed.) YES NO Form/Title J NRCI-LTI-01-E - Must be submitted for all buildings ❑ Field Inspector NRCI-LTI-02-E - Must be submitted for a lighting control system, or for an Energy Management Control System (EMCS), ❑Field Inspector to be recognized for compliance. NRCI-LTI-03-E - Must be submitted for a line -voltage track lighting integral current limiter, or for a supplementary ❑Field Inspector overcurrent protection panel used to energize only line -voltage track lighting, to be recognized for compliance. / V NRCI-LTI-04-E - Must be submitted for two interlocked systems serving an auditorium, a convention center, a El Field Inspector conference room, a multipurpose room, or a theater to be recognized for compliance. NRCI-LTI-05-E - Must be submitted for a Power Adjustment Factor (PAF) to be recognized for compliance. ❑ Field Inspector V! / NRCI-LTI-06-E - Must be submitted for additional wattage installed in a video conferencing studio to be recognized for ❑Field Inspector compliance. � CA Building Energy Efficiency Standards - 2013 Nonresidential Compliance August 2015 STATE OF CALIFORNIA INDOOR LIGHTING EQ7 GEC-NRCC-LTI-01-E (Revised 08115) CALIFORNIA ENERGY COMMISSION CERTIFICATE OF COMPLIANCE NRCC-LTI-01-E Indoor Lighting (Page 3 of 6) Project Name: Date Prepared: E. Declaration of Required Certificates of Acceptance Declare by checking all of the Certificates of Acceptance that will be submitted. (Retain copies and verify forms are completed and signed.) YES NO Form/Title NRCA-LTI-02-A - Must be submitted for occupancy sensors and automatic time switch controls. ❑ Field Inspector V NRCA-LTI-03-A - Must be submitted for automatic daylight controls. ❑ Field Inspector NRCA-LTI-04-A - Must be submitted for demand responsive lighting controls. ❑ Field Inspector A separate Lighting Schedule Must Be Filled Out for Conditioned and Unconditioned Spaces. Installed Lighting Power listed on this Lighting Schedule is only for: P CONDITIONED SPACE ❑ UNCONDITIONED SPACE F. Indoor Lighting Schedule and Field Inspection Energy Checklist The actual indoor lighting power listed on this page and on the next page includes all installed permanent and planned portable lighting systems. ❑ When Complete Building Method is used for compliance, list each different type of luminaire on separate lines. &,When Area Category Method or Tailored Method is used for compliance, list each different type of luminaire by each different function area on separate lines ❑ Also include track lighting in schedule, and submit the track lighting compliance form (NRCC-LTI-05-E) when line -voltage track lighting is installed. CA Building Energy Efficiency Standards - 2013 Nonresidential Compliance August 2015 STATE OF CALIFORNIA INDOOR LIGHTING L CEG-NRCC-LTI-01-E Revised 08/15 CALIFORNIA ENERGY CUMMI5510N — CERTIFICATE OF COMPLIANCE NRCC-LTI-01-E Indoor Lighting (Page 4 of 6) Project Name: Date Prepared: G. Installed Portable Luminaires in Offices — Exception to Section 140.6(a) ❑ This section shall be filled out ONLY for portable luminaires in offices (As defined in §100.1). All other planned portable luminaires shall be documented on next page of this compliance form. ❑ This section is used to determine if greater than 0.3 watts of portable lighting is planned for any office ❑ Fill out a separate line for each different office. Small offices that are typical (having the same general and portable lighting) maybe grouped together. This allowance shall not be traded between offices having different lighting systems. Office Portable Luminaire Schedule Office Installed Portable Luminaire Watts Per Square Foot Office Location Field Inspector 1 2 3 4 5 6 7 8 9 10 Installed If F!5 0.3, portable Watts enter luminairev a per zero; Identify Office area in c watts in 2 ° square G05 x G07 which these portable Pass Fail Complete Luminaire Description Z J this office 'v w foot if G06 > luminaires are installed (i.e., LED, under cabinet, furniture mounted Watts per (G02 x O (G04 / 0.3, direct/indirect) Luminaire G03) GOS) (G06-0.3) ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Enter sum total of all pages into NRCC-LTI- Total installed portable luminaire watts that are greater than 0.3 watts per square foot per office: 01-E; Page 1 CA Building Energy Efficiency Standards - 2013 Nonresidential Compliance August 2015 STATE OF CALIFORNIA INDOOR LIGHTING kd .Z-- CEC-NRCC-LTI-01-E (Revised 08115) CALIFORNIA ENERGY COMMISSION CERTIFICATE OF COMPLIANCE NRCC-LTI-01-E Indoor Lighting (Page 5 of 6) Project Name: Date Prepared: A separate Lighting Schedule Must Be filled Out for Conditioned and Unconditioned Spaces. Installed Lighting Power listed on this Lighting Schedule is only for: ,14 CONDITIONED SPACE ❑ UNCONDITIONED SPACE H. INDOOR LIGHTING SCHEDULE and FIELD INSPECTION ENERGY CHECKLIST Luminaire Schedule Installed Watts Location Field Inspector A B C D E F G H How wattage was determined v v � o m Complete Luminaire Description o Oo ¢ — L Ln N (i.e, 3 lamp fluorescent troffer,'E ) Z o 0 0 E j o = Primary Function area in which z— F32T8, one dimmable electronic ballast) 3 w u a o Z F- 3 these luminaires are installed Pass Fail 11 ��( '55�1� Ll ❑ ii ❑ ❑ '- ❑ / ❑ ❑ (Z ❑ )E� ❑ ❑ t v. VL ❑ ❑ ❑ ❑ ❑ ❑ ❑ INSTALLED WATTS PAGE TOTAL: _ Enter sum total of all pages into NRCC-LTI-01-E; Page 2 CA Building Energy Efficiency Standards - 2013 Nonresidential Compliance August 2015 STATE OF CALIFORNIA INDOOR LIGHTING W, CEC-NRCC-LTI-01-E Revised 08/15 CALIFORNIA ENERGY CUMMISSION CERTIFICATE OF COMPLIANCE NRCC-LTI-01-E Indoor Lighting (Page 6 of 6) 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: A--�� Documentation Author Signature: Company: � � Tom" /C /✓'� Signature Date:v�S-- Address: /O , CEA Certification Identification (if applicable): City/State/Zip: � ^ L/y j - ` Phone: _ — � C /L 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: _i r C Date Signed: / Address: /O �/�( License: /n C ` J Phone: jL f ��/ CA Building Energy Efficiency Standards - 2013 Nonresidential Compliance August 2015 INDOOR LIGHTING —LIGHTING CONTROLS 0� C)to7 CEC-NRCC-LTI-02-E Revised 05/15 1 N 7 l N. CALIFORNIA ENERGY COMMISSION CERTIFICATE OF COMPLIANCE ELM In le NRCC-LTI-02-E Indoor Lighting - Lighting Controls �r� ry�� (Page 1 of 3) Project Name: —r�� �,�/' % ' `O Date Prepared: The NRCC-LTI-02-E shall be used to document all mandatory and prescriptive lighting controls that are applicable to the project. A. Mandatory Lighting Control Declaration Statements (Indicate if the measure applies by checking yes or no below.) YES NO Control Requirements Lighting shall be controlled by self-contained lighting control devices which are certified to the Energy Commission according to the Title 20 Appliance Efficiency Regulations in accordance with Section 110.9. Lighting shall be controlled by a lighting control a system or energy management control system in accordance with §110.9. An Installation Certificate shall be submitted in accordance with Section 130.4(b). X§130.0. One or more Track Lighting Integral Current Limiters shall be installed which have been certified to the Energy Commission in accordance with §110.9 and Additionally, an Installation Certificate shall be submitted in accordance with Section 130.4(b). A Track Lighting Supplementary Overcurrent Protection Panel shall be installed in accordance with Section 110.9 and Section 130.0. Additionally, an Installation Certificate shall be installed in accordance with Section 130.4(b). All lighting controls and equipment shall comply with the applicable requirements in §110.9 and shall be installed in accordance with the manufacturer's instructions in accordance with Section 130.1. \ All luminaires shall be functionally controlled with manually switched ON and OFF lighting controls in accordance with Section 130.1(a). General lighting shall be separately controlled from all other lighting systems in an area. Floor and wall display, window display, case display, ornamental, and special effects lighting shall each be separately controlled on circuits that are 20 amps or less. When track lighting is used, general, display, ornamental, and special effects lighting shall each be separately controlled; in accordance with Section 130.1(a)4. The general lighting of any enclosed area 100 square feet or larger, with a connected lighting load that exceeds 0.5 watts per square foot shall meet the multi-level lighting control requirements in accordance with Section 130.1(b). All installed indoor lighting shall be equipped with controls that meet the applicable Shut -OFF control requirements in Section 130.1(c). Lighting in all Daylit Zones shall be controlled in accordance with the requirements in Section 130.1(d) and daylit zones are shown on the plans. f Lighting power in buildings larger than 10,000 square feet shall be capable of being automatically reduced in response to a Demand Responsive Signal in accordance with Section 130.1(e). Before an occupancy permit is granted for a newly constructed building or area, or a new lighting system serving a building, area, or site is operated for normal use, indoor lighting controls serving the building, area, or site shall be certified as meeting the Acceptance Requirements for Code Compliance in accordance with Section 130.4.(a). The controls required to meet the Acceptance Requirements include automatic daylight controls, automatic shut -OFF controls, and demand responsive controls. CA Building Energy Efficiency Standards - 2013 Nonresidential Compliance May 2015 INDOOR LIGHTING - LIGHTING CONTROLS CEC-NRCC-LTI-02-E (Revised 05/15) CALIFORNIA ENERGY COMMISSION CERTIFICATE OF COMPLIANCE NRCC-LTI-02-E Indoor Lighting - Lighting Controls (Page 2 of 3) Date Prepared: A separate document must be filled out for Conditioned and Unconditioned Spaces. This page is used only for the following: CONDITIONED SPACES ❑ UNCONDITIONED SPACES B. Mandatory and Prescriptive Indoor Lighting Control Schedule, PAF Calculation, and Field Inspection Checklist PAF Credit Calculation Z t n � (D r. D _T FD Q Standards Complying With�• o CC r K < "• n o (D (D (D t3ir m Lighting Control Schedule (✓ all that apply, or enter 'E' if Exempted) to Q- ° X -n o 7 fl. (Do r A B C D E F G H I J K L M N O Type/ Description of Lighting Control (i.e.: occupancy sensor, # `Q; i4' `Q' � ;o, p `0' Location in Building automatic time switch, of o 0 0 0 0 P o a dimmer, automatic daylight, Units a) o s N v N n m n etc...) N v z ❑ ❑ — ���/ ✓ ✓ems ❑ ❑ .�lvP� cw cd� o C). z ❑ ❑ 1007.7 04/ -5 v o. ❑ ❑ ❑ ❑ Control Credit PAGE TOTAL (Sum of Column M): IF MULTIPLE PAGES ARE USED, ENTER SUM TOTAL OF Control Credit for all pages HERE (Sum of all Column M): Enter Control Credit total into NRCC- 'Page /C- 1. /j 1.§130. 1 (a) =Manual area controls; §130.0(b) = Multi Level; §130.1(c) =Auto Shut -Off; §130.1(d) =Mandatory Daylight; §130.1(e) =Demand Responsive; §140.6(d)= Additional lighting controls installed to earn a PAF,- §140.6(d) = Prescriptive Secondary Sidelit Daylight Controls. 2. Check Table 140.6-A for correct Factor. PAFs shall not be traded between conditioned and unconditioned spaces. As a condition to earn a PAF, an Installation Certificate is also required to be filled out, signed, and submitted. CA Building Energy Efficiency Standards - 2013 Nonresidential Compliance May 2015 } INDOOR LIGHTING -LIGHTING CONTROLS CEC-NRCC-LTI-02-E (Revised 05/15) CERTIFICATE OF COMPLIANCE IA ENERGY COMMISSION NRCC-LTI-02-E Indoor Lighting - Lighting Controls (Page 3 of 3) Date Prepared: DOCUMENTATION AUTHOR'S DECLARATION STATEMENT 1. 1 certify that this Certificate of Compliance documentation is accurate and complete. Documentation Author Name: Documentation Author Signature: Company: Signature Date: J— Address: 6 «fl CEA Certification Identification (if applicable): City/State/Zip: ' I/ _ ®S� 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: y J` Responsible Designer Signature: Company: � �— Date Signed: Address: A License: ©� City/State/Zip: r _57T_ Phone: I CA Building Energy Efficiency Standards - 2013 Nonresidential Compliance May 2015