15010100CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20132 STEVENS CREEK BLVD C NTRACTOR: - i� PERMIT NO: 15010100
rcr.
OVA 'iah S: "L
OWNER'S NAME: CATHERINE CHEN
DATE ISSUED: 01/20/2015
OWNER'S PHONE: 4083630000
PHONE NO:
LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL F] COMMERCIAL E]
License Cla Lic. #�
STATE FARM - INSTALL 1 (N) NON - LUMINATED
MONUMENT
�� -. 1
Contractor t` +'�" `/'b
SIGN & REPLACE 3 NON - LUMINATED INTERIOR
ate
WINDOW /DROP SIGNS & 1 ILLUMINATED WALL SIGN
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: $5500
of the work for which this permit is issued.
Orperformance
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: 36956001.00
Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I 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 F O ED INSPECTION.
indemnity and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
J
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.
RE- ROOFS:
Signatu Date (J J
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.
❑ OWNER - 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. I will
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 Area Air Quality Management District I
performance of the work for which this permit is issued.
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance, as provided for by
the Health & Safety Code, Secti 25505 25533, 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, 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
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
ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
I 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
CUPERTINO
SIGN PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255
(408) 777 -3228 • FAX (408) 777 -3333 • buildincl akupertino.org
PROJECT ADDRESS
DPHONE
- /5o/ 56
(/
']APN#
(� �j y] ._ � /_ j � �'1�
OWNER NAME v U jl,\ �-i.� C JAI,
E -MAIL
STREET ADDRESS 1 f , e V ( %\ dife [J
CITY, STATE,I ZI`PJC(Jjn( 1 Y1 C 5o j L9
FAX
CONTACT NAME , ^,,, eI
V�,� l.�
PHONE (a �(., 1^'�l J /v
7�-�
E -MAIL
STREET ADDRESS 'i °� �
CITY, STATE, ZIP j �Y.e
FAX ,J j �lJ
❑ OWNER ❑ OWNER- BUILDER ❑ OWNERAGENT 9 CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME ��1/J / /„ ` !�Y. -�
(/V��
LICENSE NUMBER' , j /-
LICENSE TYPE c. / S
BUS. LIC #
COMPANY NAME
St 1d�
E -MAIL �JU�L>v I�� �a/�Ctd`
G�L
FAX 7
STREET ADDRESAA'0(iL4'\
CITY, STATE, Z1
V `'( ••I"I T. L / �� /'
PHONE✓ `115 j/
ARCHITECT /ENGINEER NAME
LICENSE NUMBER
BUS, LIC #
COMPANY NAME
E -MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK Y\ n
-+�P6
6[
C) Y\:e Tcep- i VNq
USE OF SFD Or Duplex ❑ Multi- Family
STRUCTURE: Commercial
ILLUMINATED
(Y /N)
SIGN TYPE
(CODE)
NO. OF
SIGNS
SIGN AREA
(l{SQ.FT.)
VALUATION
SIGN TYPE CODES.
B - BANNER SIGN M - MONUMENT (GROUND) SIGN
BL - BLADE SIGN P - PROJECTING SIGN
D - DEVELOPMENT ID SIGN SP - SPECIAL EVENT BANNER
DI - DIRECTIONAL SIGN T - TEMPORARY
E - ELECTRONIC W - WALL SIGN
READERBOARD Wl - WINDOW SIGN
C($)
1 V
II J l4-
REC
TO.;t�L oN:
By my signature below, I certify to each of the following: I am the operty owner or aut agent t property owner's behalf have read this
application and the information I have provided is correct. I have ad a Description of Wor an verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to Idi rcj n. I au o r presentatives of Cupertino to enter the above -ide ified pro crty If inspection purposes.
Signature of Applicant /Agent: Date: d
SUPPLEMENTAL INFORMATION REQUIRED
_ Site Plan
Elevations
Sign Details - including UL listing(s) applicable
Structural Calculations (if applicable)
Copy of Planning Approval Letter or Meeting with Planning prior to
Submittal of Building Permit application.
OFFICE
USE ONLY
PLAN CHECK TYPE
ROUTING SLIP
OVER- THE - COUNTER
❑ EXPRESS
❑ STANDARD
❑ LARGE
❑ MAJOR
❑ BUILDING PLAN REVIEW
❑ PLANNING PLAN REVIEW
❑ OTHER:
SignApp_2011.doc revised 03 131111
FM_7 CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
imADDRESS: 20132 STEVENS CREEK BLVD
DATE: 01/20/2015
REVIEWED BY: MELISSA
APN: 369 56 001
BP #: 5 �
VALUATION: 1$5,500
'-,PERMIT TYPE: Building Permit
Awning Sign, Non - Electric
PRIMARY Si g n
USE:
Other Elec. Insp. 0.0 $48.00
PENTAMATION 1 CEAP5
PERMIT TYPE:
WORK
INSTALL 1 N NON- LUMINATED MONUMENT SIGN & REPLACE 3 NON - LUMINATED INTERIOR
SCOPE
WINDOW /DROP SIGNS & 1 ILLUMINATED WALL SIGN
SIGN TYPE
FEE ID
QTY /FEE
QTY
FEE
1ESIGN Flee. Permit Fee: 1EPERA117'
Awning Sign, Non - Electric
1SIGNWNONE
Other Elec. Insp. 0.0 $48.00
1 ir,,7V
2SIGN
1 $286
Ground Sign
1SIGNGR /RF
Suppl. Insp. Fee:Q Reg. Q OT
1
hrs
$359
Wall Sign, Electric
1SIGNWELEC
PME Permit Fee:
1
$286
Work Without Permit? 0 Yes (F) No
$0.00
TOTALS:
$0.00
Travel Documentation Fee: 17'RAVDOC
$931.00
Strom, Motion Fee: /BSEISMICO
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District. etc.). These fees are teased on the nreliminary information availahle and are onlv an estimate. Contact the Dent for addn 7 info.
FEE ITEMS (bee Resolution 11 -053 Eft ? %1 %13)
FT#
QTY /FEE
Branch Circuits 1 1 1 $48.00
1ESIGN Flee. Permit Fee: 1EPERA117'
Suppl. PC Fee: 0 Reg. 0 OT
0.0
Other Elec. Insp. 0.0 $48.00
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District. etc.). These fees are teased on the nreliminary information availahle and are onlv an estimate. Contact the Dent for addn 7 info.
FEE ITEMS (bee Resolution 11 -053 Eft ? %1 %13)
FEE
QTY /FEE
MISC ITEMS
Suppl. PC Fee: 0 Reg. 0 OT
0.0
hrs
$0.00
Permit Fee:
$931.00
Suppl. Insp. Fee:Q Reg. Q OT
0.0
hrs
$0.00
PME Unit Fee:
$48.00
PME Permit Fee:
$48.00
Work Without Permit? 0 Yes (F) No
$0.00
Sign Master Plan: ® Yes (D No
$0.00
Travel Documentation Fee: 17'RAVDOC
$48.00
Strom, Motion Fee: /BSEISMICO
$1.54
Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC
$1.00
SUBTOTALS:
$1,077.54
$0.00 TOTAL FEE:
$1,077.54
Revised: 01/06/2015
STATE OF CALIFORNIA /� / 1,
SIGN LIGHTING (/
CEC- NlkCC- LTS -01- E(Revised 06/14) CALIFORNIA ENFRGY CnMMISSION
CERTIFICATE OF COMPLIANCE
NOTES:
NRCC - LTS -01 -E
Sign Lighting
(Page 1 of 5)
Project Name:
—
Date Prepared:
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 which they are responsible; alternatively,
Project Address:
the person with chief responsibility for construction shall prepare and sign the Certificate of Compliance Declaration Statement
Location of Sign
Phase of Sign Construction
Type of Lighting Control
Outdoor Signs ❑ Indoor Signs -�
New Signs ❑ Sign Alterations
❑ New Lighting Controls ❑ Replaced Lighting Controls Not Installing Lighting Controls
This Certificate of Compliance includes the following components (check all that apply)
❑ Mandatory Measures (Lighting Controls) Or Maximum Allowed Lighting Power ❑ Specific Lighting Sources
shall
1. Mandatory Sign Lighting Controls
NOTES:
1.
The same responsible person may install both the sign lighting power and the sign lighting controls, or a different responsible
person may install the sign lighting controls than the responsible person installing the sign lighting power.
2.
The Mandatory Measures (sign lighting controls) are required for compliance with the sign lighting Standards. If the person
responsible for installing the sign lighting power is not also responsible for the sign lighting controls, then the 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 which they are responsible; alternatively,
the person with chief responsibility for construction shall prepare and sign the Certificate of Compliance Declaration Statement
for the entire construction.
la.
Statements 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, complete parts la and lb of this form No, complete part la of this form
There are no existing sign lighting controls and I will be installing compliant sign lighting controls
2
❑ Yes No
There are no existing sign lighting controls and someone else will be responsible to install compliant sign lighting controls
3
❑ Yes 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 No
There are existing sign lighting controls that do not com ly with the applicable provision of §110.9 and §130.3 and someone
5
else will be responsible to install compliant sign lighting ontrols
❑ Yes No
CA Building Energy Efficiency Standards - 2013 Nonresidential Compliance June 2014
STATE OF CALIFORNIA
SIGN LIGHTING
S
CEC-NACC-LTS-0 1 -E(Revised 06/14) CALIFORNIA ENERGY COMMISSION
CERTIFICATE OF COMPLIANCE NRCC - LTS -01 -E
Sign Lighting (Page 2 of 5)
Project Name: 5- a I L ���� VY`\ Date Prepared:
lb. 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:
1
§130.3(a)1. All indoor sign lighting is controlled with an automatic time - switch control or astronomical time-
Y
N
NA
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)2B. 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
NA
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(a)3. Demand Responsive Electronic Message Center Control. An Electronic Message Center (EMC)
Y
N
N/A
having a new connected lighting power load greater than 15 kW has a control installed that is capable of
❑
❑
❑
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:
CA Building Energy Efficiency Standards - 2013 Nonresidential Compliance June 2014
STATE OF CALIFORNIA
SIGN LIGHTING
M[71
CEC- NRCC - LTS -01- E(Revised 06114) CALIFORNIA ENERGY COMMISSION
CERTIFICATE OF COMPLIANCE NRCC - LTS -01 -E
Sign Lighting (Page 3 of 5)
Project Name: y 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
I
J
Symbol
Or Code
Description of the Sign
OPTIONAL— Energy
Verified Label (see
instructions below)
Allotted Watts
Design Watts
Complies
Y N
Filed Inspector
Check that sign
complies
M
a
C
v°°i
>. .... _T M
f0 C
E E
1 F' �
Uj
W
3�ri
� I It
Q� w
vx
o
p
Q
N
a.+ r
F 3
vi
—
.n
0
u
❑
1
1 ►�. ,2
❑
❑
_
❑
❑
❑
❑
❑
❑
❑
❑
❑
❑
❑
❑
❑
❑
❑
A
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.
C
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
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 "I' 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).
Enter Y if the number in column His 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 June 2014
STATE OF CALIFORNIA
SIGN LIGHTING
OR
CERTIFICATE OF COMPLIANCE NRCC- LTS -01 -E
Sign Lighting (Page 4 of 5)
Project Name: --�W r v, Date Prepared:
3. Specific Lightint; 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
❑
❑
❑
❑
❑
❑
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 - Check this box only if this sign has a permanent, pre - printed, factory- installed ENERGY VERIFIED label, confirming that this sign
complies with 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 Product 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 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.
Specific Light Source Compliance Method. The sign(s) identified above use only the following lighting technologies:
List all applicable 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
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.
Neon or cold cathode lamps with transformer or power supply efficiency greater than or equal to a minimum efficiency of 75 percent
D
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
Regulations (Title 20).
9
Compact fluorescent lamps that do not contain a medium screw base sockets (E24/E26).
E
This page doubles as a field inspection checklist.
Field Inspector Notes:
CA Building Energy Efficiency Standards - 2013 Nonresidential Compliance June 2014
STATE OF CALIFORNIA
SIGN LIGHTING
It
CE'C- 11RCC- LTS -01- E(Revisecl 06/14) CALIFORNIA ENERGY COMMISSION ,bra
CERTIFICATE OF COMPLIANCE NRCC - LTS -01 -E
Sign Lighting (Page 5 of 5)
Project Name: _) Date Prepared: + ,
l I r
DOCUMENTATION AUTHOR'S DECLARATION STATEMENT
• I certify that this Certifica a of Compliance documentation is accurate and complete.
Documentation Author Name: V6 ` ' `
V . Owe V
Documentation Author Signat
Company:
Signature Date:
rapplicable):
Address: �1
J
CEA/ HERS Certification Identification (if
City /State /Zip: / p f
Phone: 71-?
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 Sign;t
Company :
fg-
Date Signed: 1 ( - j��
r 1
Address: -/ 1 � k
S t
License:
i —1
City /State /Zip: ) / � / , % ,
Phone: r^� -S
CA Building Energy Efficiency Standards - 2013 Nonresidential Compliance June 2014
STATE OF CALIFORNIA
SIGN LIGHTING
CEC- NRCC - LTS -01- E(Revised 06/14)
CAI IFORNIA FNFRr;y Cr)MMM111( N
CERTIFICATE OF COMPLIANCE
NRCC - LTS -01 -E
Sign Lighting
(Page 1 of S)
Project Name:
CL
Date Prepared:
The Mandatory Measures (sign lighting controls) are required for compliance with the sign lighting Standards. If the person
responsible for installing the sign lighting power is not also responsible for the sign lighting controls, then the owner of the sign,
Project Address:
general contractor, or architect shall be responsible to have the sign lighting controls installed.
Location of Sign
Phase of Sign Construction
Type of Lighting Control
Af Outdoor Signs ❑ Indoor Signs
10 New Signs ❑ Sign Alterations
❑ New Lighting Controls ❑ Replaced Lighting Controls ONot Installing Lighting Controls
This Certificate of Compliance includes the following components (check all that apply)
❑ Mandatory Measures (Lighting Controls) 41, Maximum Allowed Lighting Power ❑ Specific Lighting Sources
1. Mandatory Sign Lighting Controls
NOTES:
1.
The some responsible person may install both the sign lighting power and the sign lighting controls, or a different responsible
person may install the sign lighting controls than the responsible person installing the sign lighting power.
2.
The Mandatory Measures (sign lighting controls) are required for compliance with the sign lighting Standards. If the person
responsible for installing the sign lighting power is not also responsible for the sign lighting controls, then the 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 which they are responsible; alternatively,
the person with chief responsibility for construction shall prepare and sign the Certificate of Compliance Declaration Statement
for the entire construction.
la.
Statements 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, complete parts la and lb of this form No, complete part la of this form
There are no existing sign lighting controls and I will be installing compliant sign lighting controls
2
❑ Yes No
There are no existing sign lighting controls and someone else will be responsible to install compliant sign lighting controls
3
❑ Yes 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 No
There are existing sign lighting controls that do not com ly with the applicable provision of §110.9 and §130.3 and someone
5
else will be responsible to install compliant sign lighting ontrols
❑ Yes No
CA Building Energy Efficiency Standards - 2013 Nonresidential Compliance June 2014
STATE OF CALIFORNIA
SIGN LIGHTING
CEC- NRCC - LTS -01- E(Revised 06/14) CALIFORNIA ENERGY COMMISSION "�
CERTIFICATE OF COMPLIANCE NRCC - LTS -01 -E
Sign Lighting (Page 2 of 5)
Project Name: Date Prepared:
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:
1
§130.3(a)1. All indoor sign lighting is controlled with an automatic time - switch control or astronomical time-
Y
N
NA
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)2B. 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
NA
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(a)3. Demand Responsive Electronic Message Center Control. An Electronic Message Center (EMC)
Y
N
N/A
having a new connected lighting power load greater than 15 kW has a control installed that is capable of
❑
❑
❑
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:
CA Building Energy Efficiency Standards - 2013 Nonresidential Compliance June 2014
STATE OF CALIFORNIA
SIGN LIGHTING
l.
CEC- NRCC - LTS -0 1 -E Revised 06/14 CALIFORNIA ENERGY COMMISSION
CERTIFICATE OF COMPLIANCE NRCC - LTS -01 -E
Sign Lighting (Page 3 of 5)
Project Name: S 4 /\ ck (� Date Prepared: ` / l� l S
1
2. Maximum Allowed LiRhtina 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
I
J
Symbol
Or Code
Description of the Sign
OPTIONAL — Energy
Verified Label (see
instructions below)
Allotted Watts
Design Watts
Complies
y N
Filed Inspector
Check that sign
complies
Q
in
] = f0
(. E
c w=
a,t f
3 N ,..I
11
Q `. w
m
N �
0
Q
ai °—°
w
of
3
V1
CL
0
U
❑
❑
A
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.
C
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
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 'I' 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).
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 June 2014
STATE OF CALIFORNIA
SIGN LIGHTING
Il: :I /!
CEC- NRCC - LTS -01 -E Revised 06114 CALIFORNIA ENERGY COMMISSION
CERTIFICATE OF COMPLIANCE NRCC- LTS -01 -E
Sign Lighting (Page 4 of 5)
Project Name: ' . -� Date Prepared:
3. Specific Lightin> 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 Vol
below)
List all that apply
❑
❑
❑
❑
❑
❑
❑
❑
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 - Check this box only if this sign has a permanent, pre - printed, factory- installed ENERGY VERIFIED label, confirming that this sign
complies with 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 Product 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 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.
Specific Light Source Compliance Method. The sign(s) identified above use only the following lighting technologies:
List all applicable 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
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.
Neon or cold cathode lamps with transformer or power supply efficiency greater than or equal to a minimum efficiency of 75 percent
D
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
Regulations (Title 20).
9
Compact fluorescent lamps that do not contain a medium screw base sockets (E24/E26).
E
This page doubles as a field inspection checklist.
Field Inspector Notes:
CA Building Energy Efficiency Standards - 2013 Nonresidential Compliance June 2014
$TAWS OF CALIFORNIA
SIGN LIGHTING
j
CEC-NRCC-LTS-0 1 -E(Revised 06/14) CALIFORNIA ENERGY COMMISSION —
CERTIFICATE OF COMPLIANCE NRCC - LTS -01 -E
Sign Lighting (Page 5 of 5)
Project Name: Ste , Date Prepared: S -
fr
DOCUMENTATION AUTHOR'S DECLARATION STATEMENT
• 1 certify that this Certifica a of Compliance documentation is accurate and complete.
Documentation Author Name: '
Documentation Author Signat
Company:
Signature Date:
1
Address:
V Y1 — `
CEA /HERS Certification Identification (if applicable):
Cit /State /Zi
y p:Z- ;vc,w�
Phone:
S-
RESPONSIBLE PERSON'S DECLARATION STATEMENT
I certify the following under penalty of perjury, under the laws of the State of California:
1. 'rhe 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:
A^ r
+, V`-
Responsible Designer Signatuce� '��r�
Company :A
f7
Date Signed:
11
Address: 7 y
License:
City /State /Zip: J 1 ��� ��, j
Phone: jd- - C C
CA Building Energy Efficiency Standards - 2013 Nonresidential Compliance June 2014
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