15100098CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19359 STEVENS CREEK BLVD
CONTRACTOR: SIGNAGE SOLUTIONS
PERMIT NO: 15100098
CORPORATION
OWNER'S NAME: MAIN STREET CUPERTINO AGGREGATOR
1336 ALLEC ST
DATE ISSUED: 10/26/2015
OWNER'S PHONE., 40898Z/8468
ANAHEIM, CA 92807
PHONE NO: (714) 491-0299
❑ LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
INSTALL (4) ILLUMINATED WALL SIGNS AND (1)
License Class Lic. #
NON-ILLUMINATED CANOPY SIGN FOR "LAZY DOG"
Contractor /�' Sit /ll7diCJC Date i7
I hereby affirm that I:att licensed under the provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business & Professions
Code and that nay 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: $12000
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.
APN Number: 31620109.19359
Occupancy Type:
2. 1 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
APPLpCANT CERTIFICATION
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
1 certify that 1 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
180 DAYS UkOM LAST CALLED INSPECTION.
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
o r7
!�
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
Issued .y: Date:
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the ap 'cant understands and will comply with
all no ee gulatro er the ino Municipal Code, Section 9.18.
RE-ROOFS:
Signature Date /L'
I/
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, l agree to remove all new materials for
inspection.
❑ OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I arra exempt from the Contractor's License Law for one of
the following two reasons:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
1. 1, as owner of the property, or, my employees with wages as their sole
HAZARDOUS MATERIALS DISCLOSURE
compensation, will dei 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
I have read the hazardous materials requirements under Chapter 6.95 of the
construct the project(Sec.7044, Business & Professions Code).
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
I hereby affirm under penalty of perjury one of the following three declarations:
Safety Code, Section 25532(a) should I store or handle hazardous material.
1. I have and will maintain a Certificate of Consent to self-insure for Worker's
Additionally, should I use equipment or devices which emit hazardous air
Compensation, as provided for by Section 3700 of the Labor Code, for the
contaminants as defined by the Bay Area Air Quality Management District I will
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. 1 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
Ow r r or nth e a
permit is issued.Date:_,,!4�_-�-
s. I certify that in the performance of the work for which this permit is issued, I shall
not employ any person in any manner so as to become subject to the Worker's
CONSTRUCTION LENDING AGENCY
Compensation laws of California. If, after making this certificate of exemption, I
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.)
must forthwith comply with such provisions or this permit shall be deemed
Lender's Name
revoked.
Lender's Address
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
ARCHITECT'S DECLARATION
correct. I agree to comply with all city and county ordinances and state laws relating
I understand my plans shall be used as public records.
to building construction :and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
Licensed Professional
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
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19359 STEVENS CREEK BLVD
CONTRACTOR: SIGNAGE SOLUTIONS
PERMIT NO: 15100098
CORPORATION
OWNER'S NAME: MAIN STREET CUPERTINO AGGREGATOR
1336 ALLEC ST
DATE ISSUED: 10/26/2015
OWNER'S PHONE: 4089828468
ANAHEIM, CA 92807
PHONE NO: (714) 491-0299
LV LICENSED_ CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
License Class)G ' S Lic. ay (Ug 2
INSTALL (5) ILLUMINATED WALL SIGNS FOR "LAZY DOG"
Contractor �/ c t ,se%(�4*,S Date
�
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 have and will maintain a certificate of consent to self -insure for Worker's
Compensation, as provided for by Section 3700 of the Labor Code, for the
Sq. Ft Floor Area:
Valuation: $12000
performance of the work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 of the Labor Code, for the performance of the work for which this
APN Number: 31620109.19359
Occupancy Type:
permit is issued.
APPI ICANT CERTIFICATION
I certify that 1 have read this application and state that the above information is
PERMIT EXPIRES IF WORK IS NOT STARTED
correct. I agree to comply with ,all city and county ordinances and state laws relating
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
180 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
�d
granting of this perr ; d' 'o the applicant understands and will comply
Issued by: V Date: 5
with all non -point r per the Cupertino Municipal Code, Section
9.18.
RE -ROOFS:
Signature Date U _ 1 y
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.
❑ OWNLR-BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
I, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec.7044,
Business & Professions Code.
I, as owner of the property, am exclusively contracting with licensed contractors to
HAZARDOUS MATERIALS DISCLOSURE
construct the project (Sec.7044, Business & Professions Code).
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will
I hereby affirm under penalty of perjury one of the following three
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
declarations:
Health & Safety Code, Section 25532(a) should I store or handle hazardous
1 have and will maintain a Certificate of Consent to self -insure for Worker's
material. Additionally, should I use equipment or devices which emit hazardous
Compensation, as provided for by Section 3700 of the Labor Code, for the
air contaminants as defined by the Bay Ar ality Management District I
performance of the work for which this permit is issued.
will maintain compliance with the Cu n nicipal Code, Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance, as provided for by
the Health & Safety Code, Sectioi 3, and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
Owner or authorized agent: Date:
permit is issued.
I certify that in the performance of the work for which this permit is issued, l 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
CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code, I must
I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with;; such provisions or this permit shall be deemed revoked.
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
APPLICANT CERTIFICATION
Lender's Address
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
ARCHITECT'S DECLARATION
costs, and expenses which may accrue against said City in consequence of the
1 understand my plans shall be used as public records.
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
Licensed Professional
9.18.
Signature Date
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
SIGN TYPE
ADDRESS: 19359 Stevens Creek Blvd
DATE: 10129/2015
REVIEWED BY: Phuong
Phu,nh. Permit Fee.
APN: 316-20-112
BP#:
'VALUATION: 1$12,000
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE.
PRIMARY'
USE: Sign
PENTAMATION
PERMIT TYPE: 1 CEAP
WORD
...........
Install 5 illuminated wall signs for "Lazy Dog"
SCOPE
$1,430.00
SIGN TYPE
FEE ID
# Branch Circuits 1 $48.00
QTY
Phu,nh. Permit Fee.
SIGN FEE
Othc_r.blech.l 1111)
Wall Sign, ;Electric
1SIGNWELEC
cch. hasp,
5
Oec. 1u.rp. Fee:
$1,430
Permit. Fee: J
$1,430.00
Suppl. Insp. Fee:(F) Reg. Q OT Q,Q
hrs
$0.00
PME Unit Fee:
$48.00
PME Perinit Fee:
$48.00
Construction Tn.x
,I divinlslrofiLe %,ee.
Work Without Permit? Q Yes ) No
$0.00
Sign Master Plan." _ Yes (F) No
TOTALS:
Travel Documentation Fee: 1TRA VDOC
$48.00
$1,430.00
$3.36
;Tech. Plan 1,"hoick
Plrrnib. Plan Ch( -.A
# Branch Circuits 1 $48.00
I,Ie h Pvrnnr Fee.
Phu,nh. Permit Fee.
IESIGN Elec. Permit Fee: lEPERMIT
Othc_r.blech.l 1111)
OtherPtnn,b hasp.
Other Elec. Insp. El $48.00
cch. hasp,
Plumb. Insp. Fee:
Oec. 1u.rp. Fee:
NOTE: This 'estimate does not include fees due to other Departments (l.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc.)j These fees are based on the preliminary information available and are only an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolution 11-053 E . 7/f 11113)
FEE
QTY/FEE
MISC ITEMS
Plan Check ~'cue:
Suppl. PC Fee: (+) Reg. 0 OT
Q.p
hrs
$0.00
Plun76. A4ec ii./E;° ee
Permit. Fee: J
$1,430.00
Suppl. Insp. Fee:(F) Reg. Q OT Q,Q
hrs
$0.00
PME Unit Fee:
$48.00
PME Perinit Fee:
$48.00
Construction Tn.x
,I divinlslrofiLe %,ee.
Work Without Permit? Q Yes ) No
$0.00
Sign Master Plan." _ Yes (F) No
$0.00
Travel Documentation Fee: 1TRA VDOC
$48.00
Strong Nlotaon Fee: IBSEISM/CO
$3.36
Select an Administrative Item
Bldg Stds commission Fee: 1BCBSC
$1.00
-, SUBTOTALS,
$1,578.36
$0.00 TOTAL FEES
F$1,578.36
Revised: 0710212015
SIGN PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 95014-3255
CVPERTINO (408) 777-3228 - FAX (408) 777-3333 - building(c-b-cupertino.ong
15 10 () 6qz
PROJEC1 ADDRESS
N
OWNER WOO U1:-MAIL4/e,
STREET Ar)DRESS 7'i;, ZIP
rAX
CONTACT NAME PHON
L,_tv
STREETADDRESS CITY, STATE, ZiF FAX
�4�-v eo$4
1�1141_J55* (::j4f 3�117
-
0 OWNTIZ 0 OW�IEIZ-BUILDFR El OIAINERnGF,',7 0 CONFRACTOR ALN'T"RACTOR AGENT 0 ARC111TEC-1 11 ENGINEER 0 DLVELOPER 0 TENANT
CONTRAcToRNAW D/_ UCI*!�U
LICF.INISPNUMBPRJ�
LICENSE! TYPE
BUS LIC #
COMPANY NAME
E -MAP.
FAX
STREFTADDRFSS
CITY STA'11-, ZIP
pi-lo'Q
A R0 III D-17UNG EVUEA Z NIMC'
111crNsil, NUMBER
Bus LIC 9
('()NgIIANY NAM),,
L-MAdl,
FAX
STREET ADDKV58
CITY, STATE, ZIP
PIIONF
DFSCRJPTIOb of wokK
(x)z�z
j
USE OF Lf SFD,4.)r Duplex [j Multi -Family
ILLUMINATF0
SIGN "'PF
T
NO, OF
SIGN AREA
VALUATION
STRUCTUI?E: Commercial
(Y / Ij)
C
(CGDE)
I(
SIGNS
(SV.FT.)
(s)
SIG'N17YPE CODES
y
711, f-3
d, paz�
At
41
B - BANNER SIGN: M - MONUMENT (GROUND) SIGN
- PROJD7FING SIGN
BL - PLADr.SIGW !P 7
D - DF%)ELOPTAEN'l ID SKIN SP - SPECIAL EVENT BANNER
y
DI - DIREX"IT.)NAL SIGN T I'EMK)RARY
ty
2 - ELECTRONIC W WALL SIGN
W1 WINT)OW SIGN
MMEWFI)BY
TOT�aOUATION
40 yt>
By my signature Jwlow, I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
p.j�11d is have read the Q)scniptjon of Work and verify it is accurate. I agree to comply with all applicable local
application and the information lhavbro
1 1 Jtatives Cupertino to the -identified for inspection
0. g co cti authorize
ordinance and state laws rerating to
of enter above property purposes.
Date: 0
Signature of Applicant/Agont:
`ilJPPLEMENTAL INFORMATION REQUIRED
OFFICE
USE ONLY
Site Plan
PLAN (.HECK TYPE
ROUTIVG SLIP
El OVER -THF -COUNTER
El BUILDING PLAN REVIEW
Elevations
Sign rktaih;t - including UL listing(s) applicable
❑ EXPRESS
❑ PLANNVVGPLAN`RJEVTE%'
Structural Caleulation s (if applicable)
El STANDARD
❑ OTHER:
Copy of Planning Approval Letter or Meeting with Planning prior to
El LARGE
submittal of Building Permit application.
El MAJOR
Sign,14pp_2011-doc revised 03131111
STATE QF CALIFORNIA
SIGN LIGHTING
CEC-NRCC-LTS-01-E Revised 05/15 CALIFORNIA ENERGY COMMISSION
CERTIFICATE OF COMPLIANCE NRCC-LTS-01-E
Sign Lighting (Page 1 of 5)
Project Name: Date Prepared: b
A. General Information
Project Address: eftm
L J, y�
7277
Location of Sign Outdoor Signs ❑ indoor Signs
Phase of Sign Construction XNew Signs ❑ Sign Alterations
Type of Lighting Control PNew Lighting Controls ❑ Replaced Lighting Controls ❑ Not Installing Lighting Controls
This Certificateiof Compliance includes'Xe e following components (check all that apply)
❑ Mandatory measures (Lighting Controls) ❑ Maximum Allowed Lighting Power Specific Lighting Sources
1. Mandatory Sign Lighting Controls
NOTES:
r T ,
1. The same responsible person may install both the sign lighting power and the sign lig IV rent responsible
person may install the sign lighting controls than the responsible person installing the si - Elt power.
2. The Mandatory Measures (sign lighting controls) are required for compliance with the sign lighting Standards. If the person
responsiblefor installing the sign lighting power is not also responsible for the sign lightingiv it e owner of the sign,
general contractor, or architect shall be responsible to have the sign lighting controls installed.
3. if more than one person has responsibility for compliance, each responsible' person shall prepare and sign a Certificate of
Compliance and an Installation Certificate applicable to the portion of construction for whicl lt)$e_y.-aFe-r slble, alternatively,
the person with chief responsibility for construction shall prepare and sign thertificate of Compliance Declaration Statement
for the entire construction.
1a. Staterrt nts of Responsibility
Any person signing the Certificate of Compliance Declaration Statement on this NRCC-LTS-01-E shall complete Part la. Check Yes or
No for all of the following statements:
1 have responsibility for installing the sign lighting controls
1
Yes, cbmplete parts 1a and 1b of this form ❑ No, complete part la of this form
2
There ar no existing sign lighting controls and I will be installing compliant sign lighting controls
es ❑ No
There are no existing sign lighting controls and someone else will be responsible to install compliant sign lighting controls
3
❑ Yes A No
There are existing sign lighting controls that do not comply with the applicable provision of §110.9 and §130.3 and I will be
4
installing compliant sign lighting controls
❑ Yes I ZNo
There ariexisting sign lighting controls that do not comply with the applicable provision of §110.9 and §130.3 and someone
5
else will e responsible to install compliant sign lighting controls
❑ Yes o
CA Building Energy Efficiency Standards - 2013 Nonresidential Compliance May 2015
STATE OFCALIFORNIA -
SIGN LIGHTING
CEC NRCC LTS�01-E(Revised 05115)
CERTIFICATE OF COMPLIANCE
Sign Lighting
Pmjectr:'ame: ✓ A
CALIFORNIA ENERGY COMMISSION
N RCC-LTS-01-E
(Page 2 of 5)
Date Prepared: /L)
IF
1b. Mandatory Sign Lighting Controls
if the person signing the Certificate of Compliance Declaration Statement on this NRCC-LTS-01-E is responsible for complying with
the sign lighting control requirements, that person shall answer all of the following questions:
If there are construction documents, indicate where on the building plans the
mandatory measures (sign lighting control) note block can be located:
§130.3(a)1. Al{ indoor sign lighting is controlled with an automatic time -switch control or astronomical time-
Y
N
NA
1
switch control,
❑
❑
§130.3(a)2A. All outdoor sign lighting is controlled with a photocontrol in addition to an automatic time-
Y
N
NA
switch control, or an astronomical time -switch control.
❑
❑
2
EXCEPTION to Section 130.3(a)2A: Outdoor signs in tunnels, and signs in large permanently covered outdoor
Y
NA
areas that are intended to be continuously lit, 24 hours per day and 365 days per year.
❑
§130.3(a)26. All outdoor sign lighting that is ON both day and night is controlled with a dimmer that provides
the ability to automatically reduce sign lighting power by a minimum of 65 percent during nighttime hours.
Y
N
Signs that are illuminated at night and for more than 1 hour during daylight hours shall be considered ON both
❑
❑
3
day and night."
EXCEPTION to Section 130.3(a)2B: Outdoor signs in tunnels and large covered areas that are intended to be
Y
NA
illuminated both day and night.
❑
§130.3(x)3. Demand Responsive Electronic Message Center Control. An Electronic Message Center (EMC)
having a` new connected lighting power load greater than 15 kW has a control installed that is capable of
Y
N
N/A
❑
❑
4
reducing the lighting power by a minimum of 30 percent when receiving a demand response signal.
EXCEPTION to Section 130.3(a)3: Lighting for EMCs that is not permitted by a health or life safety statute,
Y
NA
ordinance, or regulation to be reduced by 30 percent.
❑
Field Inspector Notes:I
CA Building Energy Efficiency Standards - 2013 Nonresidential Compliance May 2015
STATE OF CALIFORNIA
SIGN LIGHTING '
CEC-NRCC-LTS-01 E Revised 05/15 CALIFORNIA ENERGY COMMISSION
CERTIFICATE OF COMPLIANCE NRCC-LTS-01-E
Sign Lighting (Page 3 of 5)
Project Name: r n ^9 % r Date Prepared:�-
2. Maximum Allowed Lighting Power Method of Compliance
Certificate of Compliance and Field Inspection Energy Checklist
Complete this part if there are signs using the maximum allowed lighting power method of compliance. (Complete
part 3 of
this Certificate of Compliance if there are signs using the Specific lighting sources method of compliance)
A
B
C
D E F G
H
/)
J
Symbol
OPTIONAL— Energy
Des�p
Complies
Filed
Inspector
or
DesIcription of the Sign
Verified Label (see
Allotted Watts
Watts
Y/N
Checkthat
Code
I
instructions below)
sign complies
wr'
o w �
= to
0 " �
a
�
� �
y •�
V1
vi
_
ra C
-a
v, m
Q
c
c v
v
r
v o
3
E
°
v
n
_�
_° u
o
m
ISI
❑ /
❑
❑"
❑
` ❑
❑
❑
❑
❑
❑
❑
❑
❑
❑
❑
❑
❑
❑
❑
❑
Symbol or code used on the plans (when plans are required) and other documents.
B
A description of the sign, or location of sign on the building; and the location of sign on construction documents.
OPTIONAL- Check this box only if this sign has a permanent, pre-printed, factory -installed, ENERGY VERIFIED label, confirming that the
sign complies with the Section 140.8 of the California 2013 Title 24, Part 6 Standards, using the Maximum Allowed Lighting
Power
method of compliance. The only labels that will be recognized for this purpose are ENERGY VERIFIED Certification Marks
authorized by
Underwriters Laboratories (UL) or other Product Certification Body accredited to ISO/IEC Guide 65 by the American National Standards
C
Institute in accordance with ISO/IEC 17011. Surveillance by the Accredited Certification Body shall be an ongoing annual
inspection
program carried out by a Type A Inspection body in accordance with ISO/IEC 17020. For signs with such an ENERGY VERIFIED label,
columns `D` through T are not required to be filled out. Note: Using an ENERGY VERIFIED label is an optional method to validate
compliance. An ENERGY VERIFIED label is not needed for compliance.
D
The sign area in square feet.
E
List "I" if the sign is internally illuminated. List "E" if the sign is externally illuminated.
F
Allowed watts per square foot. Enter 12 if the sign is listed as "I" in column E. Enter 2.3 if sign is listed as "E" in column E.
G
Multiply the square footage in column D times the allowed Lighting Power Density (LPD = watts) in column F.
H
Show the total installed watts in the sign, as determined according to the applicable provisions of §130(c).
I
Enter Y if the number in column H is less than or equal to the number in column G. Otherwise, the sign does not comply.
J
This page doubles as a field inspection checklist.
Field Inspector Notes:
CA Building Energy;' Efficiency Standards - 2013 Nonresidential Compliance May 2015
STATE.OF CALIFORNIA
Certificate of Compliance and Field Inspection Energy Checklist
SIGN LIGHTING
CEC-NRCC-LT&Q1 E Revised 05/15
CALIFORNIA ENERGY COMMISSION
CERTIFICATE OF COMPLIANCE
NRCC-LTS-01-E
Sign Lighting
(Page 4 of 5)
Project Name: �y:
Date Prepared:
3. Specific Lighting Source Method of Compliance
Certificate of Compliance and Field Inspection Energy Checklist
Complete this part if there are signs using the Specific lighting source method of compliance. (Complete part 2 of this Certificate
of Compliance if there are signs using the maximum allowed lighting power method of compliance)
A
B
C
D
E
OPTIONAL
Specific light source used for
Symbol
ENERGY VERIFIED
compliance
Field Inspector
or
Description
label
Shall include only lighting
Check that Sign
Code
(see instructions
technologies listed below
Complies
below)
List all that apply
❑
❑
r ��i D
❑
❑
A
Symbol or code used on the plans (when plans are required) and other documents.
B
A narrative description of the sign, or location of sign on the building; and the location of sign on construction documents
C
OPTIONAL- heck this box only if this sign has a permanent, pre-printed, factory -installed ENERGY VERIFIED label, confirming that this sign
complies wit, the Section 140.8 of the California 2013 Title 24, Part 6 Standards, using the Specific Lighting Source Method of Compliance. The
only labels that will be recognized for this purpose are ENERGY VERIFIED Certification Marks authorized by Underwriters Laboratories (UL) or
other Produ4 Certification Body accredited to ISO/IEC Guide 65 by the American National Standards Institute in accordance with ISO/IEC
17011. Surveillance by the Accredited Certification Body shall be an ongoing annual inspection program carried out by a Type A Inspection body
in accordance with ISO/IEC 17020. For signs with such an ENERGY VERIFIED label, column 'D' is not required to befilled out. Note: Using an
ENERGY VERIFIED label is an optional method to validate compliance. An ENERGY VERIFIED label is not needed for compliance.
Specific Light Source Compliance Method. The sign(s) identified above use only thefollowing lighting technologies:
List a(i appiicabie numbers (1 through 9) that apply in column D above for each row.
1
High pressure sodium lamps
Metal halide lamps that are pulse start or ceramic served by a ballast that has a minimum efficiency of 88 percent or
2
greater- Ballast efficiency is the measured output wattage to the lamp divided by the measured operating input wattage
when tested: according to ANSI C82.6-2005,
Metal (halide lamps that are pulse start that are 320 watts or smaller, are not 250 watt or 175 watt lamps, and are served by
a ballast that has a minimum efficiency of 80 percent.
3
Ballastefficiency is the measured output wattage to the lamp divided by the measured operating input wattage when tested
accord fngtoANSI C82.6-2005.
Neon of cold cathode lamps with transformer or power supply efficiency greater than or equal to a minimum efficiency of 75 percent
4
when the transformer or power supply rated output current is less than 50 mA. The ratio of the output wattage to the input wattage is at
100 percent tubing load.
Neon or cold Cathode lamps with transformer or power supply efficiency greater than or equal to a minimum efficiency of 68 percent
5
when the transformer or power supply rated output current is 50 mA or greater. The ratio of the output wattage to the input wattage is at
100 percent tubing load.
6
Fluorescent lighting systems meeting one of the following requirements: A. Use only lamps with a minimum color rendering index (CRI) of
80; or B Use only electronic ballasts with a fundamental output frequency not less than 20 kHz.
7
Light emitting, diodes (LEDs) with a power supply having an efficiency of 80 percent or greater;
Single voltage external power supplies that are designed to convert 120 volt AC input into lower voltage DC or AC output, and have a
8
nameplate output power less than or equal to 250 watts, shall comply with the applicable requirements of the Appliance Efficiency
Regulat%ons (Title 20).
9
Compact fluorescent lamps that do not contain a medium screw base sockets (E24/E26).
E
This page dorables as a field inspection checklist.
Field Inspector Motes:
CA Building Energy Efficiency Standards - 2013 Nonresidential Compliance May 2015
STATE, CF CALIFORNIA
SIGN LIGHTING
CEC-NRCC-LTS-101.6 Revised 05/15 CALIFORNIA ENERGY COMMISSION
CERTIFICATE OF COMPLIANCE NRCC-LTS-01-E
Sign Lighting (Page 5 of 5)
Project Name: Date Prepared: 4414O
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:
hAr
b
Address:
CEA Certification Identification if applicable
City/State/Zip:®
Fr
Phone: 9
RESPONSIBLE PERSON' DECLARA ION S ATEMENT
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 forthe building design or system design
identified on this Certificate of Compliance (responsible designer).
3. The energyfeatures and performance specifications, materials, components, and manufactured devices for the building design or system
design idetified on this Certificate of Compliance conform to the requirements of Title 24, Part 1 and Part 6 of the California Code of
Regulation's.
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'lapproval 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 provide he buil g owner occupancy.
Responsible Designer Name?..
Responsible Designer Signature: ,`-'—
Company:!.
Date Signed:
Address:
License: �O
JI -
CityJState%Zip:®�
Phone:
o t{'A'i �/ �•
CA Building Energy Efficiency Standards - 2013 Nonresidential Compliance May 2015
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