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15070149
L_ CITY OF CUPERTINO BUILDING PERMIT I BUILDING ADDRESS: 10815 N WOLFE RD CONTRACTOR: S D DEACON CORP OF PERMIT NO: 15070149 CALIFORNIA I i OWNER'S NAME: CUPERTINO VILLAGE LP 7745 GREENBACK IN STE 250 DATE ISSUED: 10/07/2015 OWNER'S PHONE: 9257889971 CITRUS•HEIGHTS, CA 95610 PHONE NO: (916)969-0900 LICENSED CONTRACTOR'S DECLARATION License Class--A-B—Ifn Lie. # 7 6 6) e'j a%5 Contractor L a can C'O rP Date S_ 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: 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 performance of the work for which this permit is issued. 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. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities,ju g costs, and expenses which may accrue against said City in consequen e 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 1r Date�j 11 OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: t. _I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) 2. I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three declarations: �. I have and will maintain a Certificate of Consent to self -insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 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. 3. I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If, after making this certificate of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter 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 JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑ PANCHEROS MEXICAN GRILL - STE # 105 - T.I. TO BUILD OUT SHELL 2,067 S.F. (CUPERTINO VILLAGE) Sq. Ft Floor Area: Valuation: $390000 APN Number: 31605056.10815 I Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. '- RE -ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. Signature of Applicant:_ ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as definedby the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. Owper or authorized agent: --- Date:----> CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Address ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional CUPERTINO• ❑ NEW CONS—,RT CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildingq( cupeliino.orq �" ❑ ADDITION TERATION / TI ❑ REVISION /DEFERRED ORIGINAL PERM®TT'57 PRADDRESS ,o�31DRO, APN �V `r OWNERNAME C ,eP4jh0 V1 (I9 L' I PHONE6J25- IO!9-g9 ) E-MAIL-f-dewel�@ Ilne©Re Born STREET ADDRESS 3�j33 NeW A- i q_ aa A,— CITY, STAT IP CONTRA ORN LIC NSF h IS � I BUS. LIC CON24UY NAME o Com CONTACT NAME Ca �::RaGe�ty%Gh FAX - 411 E- ;' (CAj�eSkeadfs o La STREET ADD SS Q U �� S ET ADP R S t >enba�k- I�►►ne 25d A 16 ZIP �* �/jw, O (J 1`� R 6,5qo� 2 G� Ij 2/� n-849-2.,150 �l�-J4 1 4,150 0 0'4MR ❑. OWNER-BU'LDER ❑ O)hNERAGENT ❑ CONTRACTOR ❑ CON UCTORAGENT X ARCHITECT ❑ ENGD\mR. ❑ DEVELOPER ❑ TENANT oG� LIiEaTE BUS. LIC CON24UY NAME o Com -'MAIL S . � e 160 c cec�acon ra m FAX VALUATION (S) . & 7 29- Oq 0o S ET ADP R S t >enba�k- I�►►ne 25d CITY, SrP �'�gSGco i I �' V �t2�s -70-agoo AR ECT/ENG TEFR ME �' LICEISE NUMB ()1-77o4 BUS. LIC R COMPANY NAME kA Q_' E -M LF t'flea s G�aoC�-� . ca -- 12- 3 qq-2g 30 STATE, ZIP )I o PHONE 'q, e r m' DlrSCRIPTION OF WORK , ®�. -C\A o US -� hA • Vit e �e Q-+�v�dt hrj oa ten watts, EXISTING USE 5� b�yJIj��Q► PROPOSED USE CONSTR TYPE I 4 STORIES �� (�• (�, ,, l USE TYPE OCC. I SQ.FT. VALUATION (S) AREA i/ V (0 AREA a m DEMO � l !/ /� �V j'O`THER rin�EA !/ " (' _JG � I �' V f✓" `0 a/ 1 o / U 0c) BATHROOM1 KITCHEN - REM DE A REM1V �A REMODEL AREA R / LI 7D' POR A DECK / REA N I TOTAL DE ORCH AREA N � G )r ARE' AV: fw�- TTACH ❑ ATTACH - m D',AIE LINGUNITS: IS A SECOND UNIT ❑ YES ADDED? XNO SECOND STORY ADDITION? ❑YES ABEING RNO �"❑ PRE -APPLICATION PLAVNINGAPPLR YES IF YES, PROVIDE COPY OF ( NO PLANNING APPROVAL LETTER IS THE BLDG AN EICHLERHOME? YES ANO Mail; - - N s Y�7-UA_ 'rIOIJ; 90 Icy my signature below, I certify to each of the followins: I am the property d4arerbrauth&ize - tt� ac on ovmer's behalf. I have read this application and the information I have provided is correct. I have read the Description of Wer and verify it rate. I agree to comply with all applicable Iocal ordinances and state laws relating to b, ilding construction. I au�thjo�rize repr n 'ves'of Cupertino to enter the above -identified property for inspection purposes. Signature of Applicant/Agent: �/ `�! ' • Date: SUPPLEMENTAL IATFORMATION REQUIRED - \'�. New SFD or Multifamily dv ,,ellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building permit for new building. _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure form if any Hazardous Materials are being used as part of this project. _ Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application. Bldg.4pp_2011. doc revised 06121111 CITY OF CUPERTINO FFF F.RTIMATnR _ RTTTT 717FNt- nTV1rC1rl11&T 19 ADDRESS: 10815 N WOLFE RD STE 105 ♦ A". DATE: 07/21/2015 V1 REVIEWED BY: MELISSA APN: 316 05 056 BP#: *VALUATION: $390,000 'PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement PRIMARY Commercial Building SE:PERMIT PENTAMATION 11-B,I11-B,IV,V-B TYPE: 1A TIA WORK PANCHEROS MEXICAN GRILL - STE # 105 - T.I. TO BUILD OUT SHELL 2,067 S.F. SCOPE $1,253.60 IATIINSP OCCUPANCY TYPE: TYPE OF CONSTR. FLR AREA S.L PC FEES PC FEE ID BP FEES BP FEE ID A (Tenant Improvements) 11-B,I11-B,IV,V-B 2,067 $2,495.72 IATIPLNCK $1,253.60 IATIINSP Hew.. Ina'r Fee: PME Plan Check: $0.00 Permit Fee: $1,253.60 Suppl. Insp. Feer Reg. C) OT 0 0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 TOTALS: 2,067 $2,495.72 ' $1,253.60 , MEG1 HOETRI,Y Yes, �. No I'LIJMB,:HaURI,I' YEs << .No ELEG,.HQU-RLY; : Yes ONO Afech. Karl Check 1'I'1trsh. Plan C'hee,', 1,76-i:.% Plan Check llech. 1'enilit Fee: -1- F'lurai>, Perot l Fee: Elec. Penwil Fee: Cizh�'r h. Irrsj' ED 07her Plurn > Insp. 011ier E-7ec. Iris£a. Li I Ili3j7. I luy?lh Insp. Fee: Hew.. Ina'r Fee: lYuiC: 1 nzs estimate Goes not include fees due to other Departments (i.e. Planning, Public Works; Fire, Sanitary Sewer District, School District.etc.). These fees are hated an the nrnliminany infarmntian nvni/nh/o n»d oro ""h' n" oetdmn}o. ('`oro}nn} }l,n Pont F r nidida �d iwfn FEE ITEMS (Fee Resolution 11-053 f f. 7/11131 FEE QTY/FEE MISC ITEMS Plan Check Fee: $2,495.72 Select a Misc Bldg/Structure or Element of a Building Suppl. PC Fee: Reg. 0 OT0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $1,253.60 Suppl. Insp. Feer Reg. C) OT 0 0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 A(hnirzWrative Fee: 0 Work Without Permit? 0 Yes E) No $0.00 Advanced Planning Fee: $0.00 Select a Non -Residential ure Building or Structure 0 A J� Tr m?el L l o rim n-',•": don I° ees: Strom Motion. Fee: IBSEISMICo $109.20 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $16.00 SVBTOTALSc $3,874.52 $0.00 TOAL FEE; ; $3,874.52 Revised: 07/02/2015 Building Department I City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR / SUBCONTRACTOR LIST *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: d SUBCONTRACTOR JOB ADDRESS: 0 $ I lWa fr LOS PERMIT # BUSINESS LICENSE # Cabinets & Millwork OWNER'S NAME: kc4i,ld,,Aj,rPHONE # ). S ^ q b % ) Cement Finishing GENERAL CONTRACTOR: ,Cquj C BUSINESS LICENSE # ZS3 o v Electrical ADDRESS: / &ck I c 2 CITY/ZIPCODE: C' *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: d SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork F-U.s. w 0e C % ) Cement Finishing v Electrical 'c--/ Excavation C� Fencing Flooring / Carpeting Linoleum / Wood i Glass / Glazing V 4 Heating tl o n /h to kR rc' ► S 6 Insulation Landscaping Lathing Masonry VPainting / Wallpaper L N h S I Paving Plastering V1 Plumbing AP S V I Roofing i} / k f /'oA Z% Septic Tank Sheet Metal ASO" /" *,-64 t ,A # 1206 \/ Sheet Rock lr /( f r, fr d 3 6 S V/ I Tile t7 G T' I • %t )1 10 Owner / Contractor Signature Date -HIP) L'Lm6�' 3(Okg I i AALBERT ESCL'N i SALVADOR, P.E.. C.S.Gt , BUILDING OrFICJAL UPERTI I 10300 TORRE AVENUE = CUPERTINO, CA 95014-3255 (4083) 777-3228 - FAX j413-31 777-3333 buiigl q7'�c Inc. e; PURPOSE For residential single family or duplex construction, there are cases where gas and electric utilities are requested to be released prior to the issuance of the certificate of occupancy. Upon approval from the building inspector, the City of Cupertino is allowing troth utilities to be released prior to the final sign -off of the building. INSTRUCTIONS 1. Download this form at: hitt-.r:;� ••. c, i 3.cir..ra Ie� 1, a 29. 2. Complete the form and obtain signatul-eS f 01TI bath the olwier of the property and the primary contractor. 3. Fax, E -Mail, Mail or hand deliver the original signed form to: City of Cupertino Building Division Attu: Utility= Release Request Form 408-7 77-322,3 office 10300 Torre Ave. 408-7117-3333 fax Cupertino, CA 95014' t�i3ila r � :ia�a r rr c=. 4. Schedule a Gas Meter release inspection (4403) and/or Electric Meter Release inspection (#=104), Please note, a Gas Test inspection (9506) i-s'required prior to or at the :same time of the Gas Meter Release inspection: BUILDING INFORMATION (Please complete the following information): PN iLhnERnnIT#: (1' DATE: t SITE ADDRESS: 10815 North Woft Rd, Ste. 105 Cupertino, CA 95014 OWNER'S NAME: PHONE #: Q26.:iU9.�996 Heavenly holding Ventures, Inc. FAX: 9?5:999.8"972 TAILING ADDRESS (if different from site address). 6352 C1ar6 Ave. Dublin. CA 94568 CONTRACTOR: PHONE #: 916-469-10900 Peawn FAX #. 918:729:490Q CONTACT: PHONE 4: 916.497=3485 Anthony 5zu FAX #: ie -729-9900 request the City to release my utilities prior to obtaining a final inspection approval for the building- ffully understand the occupant; pf he building cannot move into the residence until they receive all of the required final sign -offs and the City has issued a certificate of iccupancy for the building. )wnar........ 4E, ... ...; :Fnrr?. NeatherHany_.. hate..,... ,. .ontractor ... Print.., :¢ik ljdlhtvf?eleweForm 20JLdocrevised,08,0111 C . STATE OF CALIFORNIA LIGHTING CONTROL ACCEPTANCE DOCUMENT CFC-NRCA-1 TI -M -A tP.uic i (KH rl CERTIFICATE OF ACCEPTANCE vv NRCA-LTI-02-A Lighting Control Acceptance Document (Page 1 of 5) Project Name:{7q r � r I G r► I ( Enforcement Agency: '' (C t Cu f 2 cr Permit Number: Project Address: , A r _. 10815V t' /�,,'/ "'v U e r t i n o Zip Code:qsblLi Note: For more than 3 spaces attach additional sets of pages 2I Z Enforcement Agency Use: Checked by/Date /' A% through 5, as required. Automatic Shut-off Controls: Automatic Time Switch Control and Occupant Sensor Intent: Lights are turned off or set to a lower level when not needed per Section 110.9(a) & 130.1(c). Guidance This acceptance test form must be filled out for all newly -installed lighting control systems of the following types: I. Automatic Time Switch Controls II. Occupancy Sensors 111. Partial -OFF occupancy sensors IV. Partial -ON occupancy sensors (only if used to claim a Power Adiustment Factor) 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 form NRCA-LTI-03-A; for demand responsive lighting controls, use acceptance test form NRCA-LTI-04-A. The tests on this certificate are required by Section 140.6(a)2 and 130.4(a) of the Building Energy Efficiency Standards 2013. 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 include, but are not limited to: hand-held amperage meter, power meter, or light meter 01 Automatic Time Switch Controls Construction Inspection—confirm for all listed in Section B a. All automatic time switch controls are programmed for (check all): [,K Weekdays p,' Weekend Cir Holidays b. Document for the owner automatic time switch programming (check all): [3' Weekdays settings ['' Weekend settings L" Holidays settings ❑ Set-up settings ❑ Preference program setting OW' Verify the correct time and date is properly set in the time switch per' Verify the battery is installed and energized fi;K Override time limit is no more than 2 hours R' 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 four feet of any HVAC diffuser ❑ Ultrasonic occupancy sensors do not emit audible sound 5 feet from source CA Building Energy Efficiency Standards - 2013 Nonresidential Compliance May 2015 STATE OF CALIFORNIA LIGHTING CONTROL ACCEPTANCE DOCUMENT CEC-NRCA-LTI-02-A f RPvkPd 05/151 _..__ _. _ _ _ _ __ _. _ _. _ . . 42 W CIYCRV 1 V VMMIJJIVIV � CERTIFICATE OF ACCEPTANCE NRCA-LTI-02-A Lighting Control Acceptance Document (Page 2 of 5) Project Name: OJAC Iver 's Me Cs rt I Ellforceme envy: o Permit Number: Iso -40 Project Addrew 10315 Uiol City: CAA L Code: e tr ,rio �— B. Functional Testing of Lighting Controls Representative Spaces Selected For every space in the building, conduct functional tests I through V 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) b The occupant sensor does not trigger a false "on" from movement in an area adjacent to the controlled space or from HVAC operation Y / N Tested space/ room name: r-,I'1.,Aen Ye�0. Space Type (office, corridor, etc) E2od prep li2/ 01 �— Status indicator or annunciator operates correctly Y / N Untested areas/rooms Y / N b. Tested space/ room name: 'r1rQ001 Space Type (office, corridor, etc) O_Wl cei Y / N 02 Y / N Step 3: System returned to initial operating conditions Y / N Untested areas/rooms Y / N Tested space/ room name: Space Type (office, corridor, etc) ❑ 03 Untested areas/rooms Functional Tests Tested Space Number Confirm compliance (Y/N) for all control system types (I-V) 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 Q N Y / N Y / N b Verify the switch only operates lighting in the ceiling -height partitioned area in which, the switch is located l TJX N Y / N Y / N Step 2: Simulate unoccupied condition a. All lighting, including emergency and egress lighting, turns off. Exempt lighting may�/ N Y / N Y N remain on per Section 130.1(c)1 and 130.1(a)1. / Manual override switch allows only the lights in the selected ceiling height b. partitioned space where the override switch is located and remain on no longer than & N Y / N Y / N 2 hours (unless serving public areas and override switch is captive key type). Step 3: System returned to initial operating conditions Y N Y / N Y / N 02. Occupancy Sensors 2 1 3 Step 1: Simulate an unoccupied condition a. Lights controlled by occupancy sensors turn off within a maximum of 30 minutes from start of an unoccupied condition per Standard Section 110.9(b) N N Y / N b The occupant sensor does not trigger a false "on" from movement in an area adjacent to the controlled space or from HVAC operation Y / N O, N Y / N Step 2: Simulate an occupied condition a. Status indicator or annunciator operates correctly Y / N N Y / N b. Lights controlled by occupancy sensors turn on immediately upon an occupied condition OR sensor indicates space is 'occupied" and lights may be turned on manually Y / N 1� N Y / N Step 3: System returned to initial operating conditions Y / N N Y / N CA Building Energy Efficiency Standards - 2013 Nonresidential Compliance May 2015 STATE OF CALIFORNIA LIGHTING CONTROL ACCEPTANCE DOCUMENT CEC-NBCA-LTI-02-A(Rav4sedns(t9t--•__---_-----•_----- CERTIFICATE OF ACCEPTANCE r9CI\V t I.VMMIJJIVIV NRCA-LTI-02-A Lighting Control Acceptance Document (Page 3 of 5) Pro ct N 1e Tla N � \ � Enforcem nt Agenry: 7l Perrnit Number: '1 r I 014 Project "dress: o City:Zip # G Code: of " , e n o I,Lf 03. Partial Off Occupancy Sensor 1 2 3 Step 1: Simulate an unoccupied condition Lights go to partial off state within a maximum of 30 minutes from start of an a' unoccupied condition per Standard Section 110.9(a) Y / N Y / N Y / N 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 Y / N Y / N Y / N aisle, activity beyond the stack or aisle shall not activate the lighting in the aisle or Y / N Y / N Y / N Step 2. Simulate an unoccupied condition stack. Both stages (automatic on and manual on) lights turn off within a maximum of 30 In the partial off state, lighting shall consume no more than 50% of installed lighting minutes from start of an unoccupied condition per Standard Section 110.9(a) Y / N Y / N Y / N power, or: The occupant sensor does not trigger a false "on" from movement in an area adjacent • No more than 60% of installed lighting power for metal halide or high to the controlled space or from HVAC operation Y / N Y / N C. pressure sodium lighting in warehouses. • No more than 60% of installed lighting g g power for corridors and stairwells in Y/N Y / N Y / N which the installed lighting power is 80 percent or less of the value allowed under the Area Category Method. Light level may be used as a proxy for lighting power when measurements are taken Step 2: Simulate an occupied condition The occupant sensing controls shall turn lights fully ON in each separately controlled a. areas, Immediately upon an occupied condition Y / N Y / N Y / N 04. Partial On Occupancy Sensors 1 2 3 Step 1. -Simulate an occupied condition. Verify partial on operation. Immediately upon an occupied condition, the first stage activates between 30 to 70% a' of the lighting automatically. Y / N Y / N Y / N After the first stage occurs, manual switches allow an occupant to activate the b. alternate set of lights, activate 100% of the lighting power, and manually deactivate Y / N Y / N Y / N all of the lights. Step 2. Simulate an unoccupied condition Both stages (automatic on and manual on) lights turn off within a maximum of 30 a. minutes from start of an unoccupied condition per Standard Section 110.9(a) Y / N Y / N Y / N b The occupant sensor does not trigger a false "on" from movement in an area adjacent to the controlled space or from HVAC operation Y / N Y / N Y / N (.A Bwucnng Energy Efficiency Standards - 2013 Nonresidential Compliance May 2015 STATE OF CALIFORNIA LIGHTING CONTROL ACCEPTANCE DOCUMENT CEGNRCA-1 TW9-A /P—i—i nrli It CERTIFICATE OF ACCEPTANCE ,-1AUrVKI41M CIVCKUY UUMMISJIUN NRCA-LTI-02-A Lighting Control Acceptance Document (Page 4 of 5) Project Name:Enforcem M C r >f I I t Aaency: 2 Perini[ Number: - Step 1. Verify area served and compare actual PAF with claimed PAF. Refer to Functional Test II. i l sty I Project Address: D Cm,. �— ino hp Code o[ -e. r I K 05. Additional test for Occupancy Sensors Serving Small Zones in Office Spaces Larger PASS / PASS / PASS / than 250 Square Feet, to Qualify for a Power Adjustment Factor (PAF) 1 2 3 First, complete Functional Test 2 (above) for each controlled zone Step 1. Verify area served and compare actual PAF with claimed PAF. Refer to Functional Test II. a. Area served by controlled lighting (square feet) If Occupancy Sensor (On Off Control) (all answers must be Y). b Enter PAF corresponding to controlled area from line (a) above (<125sf for PAF=0.4, stacks, corridors, stairwells in nonresidential buildings must also be accompanied by 126-250sf for PAF=0.3, 251-500sf for PAF=0.2). passing Test I or Test II. C. Enter PAF claimed for occupant sensor control in this space from the Certificate of IV Partial On Occupant Sensor for PAF (all answers must be Y). Compliance V Occupant Sensor serving small zones for PAF (all answers must be Y). Also must pass d The PAF corresponding to the controlled area (line b), is less than or equal to the PAF claimed in the compliance documentation (line c) Y / N Y / N Y / N Sensors shall not trigger in response to movement in adjacent walkways or e. workspaces. Y/ N Y/ N Y/ N f All steps are conducted in Functional Test 2 "Occupancy Sensor (On Off Control)" and all answers are Yes (Y) Y / N Y / N Y / N C. Testing Results PASS / PASS / PASS / FAIL FAIL FAIL I Automatic Time Switch Controls (all answers must bey). If Occupancy Sensor (On Off Control) (all answers must be Y). III Partial Off Occupancy Sensor (all answers must be Y). For warehouses, library book stacks, corridors, stairwells in nonresidential buildings must also be accompanied by passing Test I or Test II. v l IV Partial On Occupant Sensor for PAF (all answers must be Y). V Occupant Sensor serving small zones for PAF (all answers must be Y). 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 - 2013 Nonresidential Compliance May 2015 STATE OF CALIFORNIA LIGHTING CONTROL ACCEPTANCE DOCUMENT CEC-NRCA-1 TI -07-A /Revisarl WWI Al N - N M� �Qi CERTIFICATE OF ACCEPTANCE YCr�V 1 \aVmA11JJI MY NRCA-LTI-02-A Lighting Control Acceptance Document (Page 5 of 5) Pmject Na ` M Enforce nt Agency: Address: 11(91-70 i nwvo Ct. Permit Number: -5 r S.11 Phone: 40 _ _ 0 FIELD TECHNICIAN'S DECLARATION STATEMENT I certify the following under penalty of perjury, under the laws of the State of California: Project Address: City: 3. The construction or installation identified on this Certificate of Acceptance complies with the applicable acceptance requirements Zip Code: 0 u per+1110 been completed and signed by the responsible builder/installer and has been posted or made available with the building permit(s) 5014 DOCUMENTATION AUTHOR'S DECLARATION STATEMENT 1. 1 certify that this Certificate of Acceptance documentation is accurate and complete. Documentation Author Name: r 2 rrMayers Documentation Author Signator Documentation Author Company Na Date Signed: / ,L `� _ 1 1S Address: 11(91-70 i nwvo Ct. CEA/ATT Certification Identification (if applicable): 97 City/State/Zip: ,u n J -OS d� 15 ! 3 Phone: 40 _ _ 0 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: fie- rr er5 Field Technician Sign re: Field Technician Company Name: QV (A Position with Compo e): •� Address: 1 i� ATT Certificationt�otion("d applicable): E City/State/Zip: C'a`m �}-� �, ^ !1 Phone:�O 57S_ `,�� Date Signed: 12- V 207ts-- 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 Acceptance Person Name:r Responsible Acceptance Person Sig Responsible Acceptance Person Company Name: Position with Company (Title): M Address:ME 70 oo �. License: G -lo 710 is City/State/Zip Phone: IiOS _-712_1 .7Z Date Signed: I2/a, is CA Building Energy Efficiency Standards - 2013 Nonresidential Compliance May 2015