Loading...
11120016 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20530 TOWN CENTER CONTRACTOR:COULTHARD IDENTITY PERMIT NO: 11120016 GROUP INC/ OWNER'S NAME: CIVIC PARK CUPERTINO LLC 5437 CENTRAL AVE STE 8 DATE ISSUED: 12/01/2011 OWNER'S PHONE: 4084363671 NEWARK,CA 94560 PHONE NO:(650)858-1221 91 Cl-q5' ^ �LICENNSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r— ELECT r PLUMB r— License Class V�'q, Lic.H �0 Uy-) MECH r— RESIDENTIAL F COMMERCIAL f— Contractors j1t�� 1--, OLWO Date )Z ' .7 I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPT{ON:CUPERTINO ORAL SURGERY&DENTAL IMPLANTS- (commencing with Section 7000)of Division 3 of the Business&Professions INSTALL / Code and that my license is in full force and effect. ILLUMINATED CHANNEL LETTER SIGN 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 performance of the work for which this permit is issued. 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. Sq.Ft Floor Area: Valuation:$5300 APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is APN Number:36955082.20530 Occupancy Type: 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, PERMIT EXPIRES IF WORK IS NOT STARTED costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR with all non-point source regulations per the Cupertino Municipal Code,Section 180 DAYS FROM LAST CALLED INSPECTION. 9.18. Signature Date LT_ 1 14 Issued by: Date: ❑ OWNER-BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractor's License Law for one of RE-ROOFS: the following two reasons: Al I roofs shall I be inspected prior to any roofing material being instal led.If a roof is 1,as owner of the property,or my employees with wages as their sole compensation, installed without first obtaining an inspection,I agree to remove all new materials for will do the work,and the structure is not intended or offered for sale(Sec.7044, inspection. Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to Signature of Applicant: Date: construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER declarations: I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE Compensation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain Worker's Compensation Insurance,as provided for by California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain Section 3700 of the Labor Code,for the performance of the work for which this compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Safety Code,Section 25532(a)should I store or handle hazardous material. permit is issued. Additionally,should I use equipment or devices which emit hazardous air I certify that in the performance of the work for which this permit is issued,I shall contaminants as defined by the Bay Area Air Quality Management District 1 will not employ any person in any manner so as to become subject to the Worker's maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Compensation laws of California. If,after making this certificate of exemption,I Health&Safety Code,Sections 25505,25533,and 25534. 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. Owner aria e Date: 34/1 APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY 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 I hereby affirm that there is a construction lending agency for the performance of Hork's to building construction,and hereby authorize representatives of this city to enter for which this permit is issued(Sec.3097,Civ C.) upon the above mentioned property for inspection purposes.(We)agree to save Lender's Name indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the Lender's Address granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION 9.18. 1 understand my plans shall be used as public records. Signature Date Licensed Professional IlL2�vc� til.o SIGN PERMIT APPLICATION 10 COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 CUPERTINO (408)777-3228•FAX(408)777-3333•building cDcupertino.org PROJECT ADDRESS a6)6,30 O63O _)7 0j/Nj n', I7X ,/^ i APN N v O OWNER NAMEq/v JC Pf}R K CUUPCE _I r7tl,)O GLCP/-HONE E-MAIL (� x/08 Z -31o�/ STREET ADDRESS CITY,STATE,ZIP FAX P.o �3ox ),3c;2-,6- �ti1_6 /fteCW `)4a2�,-a CONTACT NAME'ENNr � 1 6-p'tjno� PH I � E-MAIL STREET ADDRESS CITY,STATE, ZIP mom cfi gv � rax ❑ OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT VZ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICE SE LICE E TYPE BUS.LIC N �vEN!�- GD ULTH 'D =& o � L-L v C MPANY NAMEE-MAIL X 00, 1 b-�0P Inco 016-/t/ le 858 -c9-/4/`1 STREET ADDRESSa �o�rrpc. src.4 , P NEcITF 7011- y636 !�7p 62�_g -2 f> � ARCHITECT/ENGINEER NAME `v' LICENSE NUMBER BUS.LIC N COMPANY NAME , E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE DESCRIPTION OF WORK New S"t✓�"' d� �'�i�nl��`� LE t7Ei�� 7z� ,3vi�iNG DC- USE OF ❑ SFD or Duplex ❑ Multi-Family ILLUMINATED SIGN TYPE NO.OF SIGN AREA VALUATION STRUCTURE: ® Commercial (Y/N) (CODE) SIGNS (SQ FT.) ($) SIGN TYPE CODES B - BANNER SIGN M - MONUMENT(GROUND)SIGN BL - BLADE SIGN P - PROJECTING SIGN r V v D - DEVELOPMENT ID SIGN SP - SPECIAL EVENT BANNER DI - DIRECTIONAL SIGN T - TEMPORARY E - ELECTRONIC 0 WALL SIGN READERBOARD WI - WINDOW SIGN /� RECEIVED BY: /1 Q TOTAL VALJ,{/��ON Oo By my signature below,1 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 application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to buildin construction. I authorize representatives of Cupertino to enter the 7bjd7e �tified2property for inspection purposes. Signature of Applicant/Agent: Date: � SUPPLEMENTAL INFORMATION REQUIRED OFFICE Use ONLY ,19.t/ " De Plan ��PL�AN CHECK TYPE ��ROUTING SLIP "U,ICvations LTOVER-THE-COUNTER BUILDING PLAN REVIEW 2n Details-including UL listing(s)applicable ❑ EXPRESS ❑ PLANNING PLAN REVIEW ctural Calculations(if applicable) ❑ STANDARD ❑ OTHER: Copy of Planning Approval Letter or Meeting with Planning prior to ❑ LARGE submittal of Building Permit application. ❑ MAJOR SignApp_201 1.doc revised 03/31/11 Building Department 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 JOB ADDRESS: 90!tv30 sst� 06NTa /-elf PERMIT# O d OWNER'S NAME:0 vi---Aq�CU,°W—T pjo t LC PHONE# C! GENERAL CONTRACTOR:COU-TFt�p /D&O 1,57EV00 K. BUSINESS LICENSE# ADDRESS: CITY/ZIPCODE: *Our municipal code requires all busin sse wor ing int a 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: - �-�j�7- o� �N�;,�2.,g.P�� � Signature Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring/ Carpeting Linoleum /Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting/Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile OwiVer/Contractor Signature Date Halo Channel Letters w/ Face Lit Logos LED Illumination - Individually Mounted Client Name - City CA WMOUILDING� IVISIV4-CUPEFCC1t� App on$ Tim 132.7' This set of Plans ands It Is unle Am job site ire r utap �th fns P R T I lei chan9 therefrom,W„ ° aPP��fromA in �f is la The stamp 9 m�or t .. o be held to ' Of any PrO 6Y �j -I t �'� r- CE SD RMiT NO. i- DECO 1 2011 A Fron It Logos, Halo-Channel Letters w/LED, Individually Mounted • Front View SCALE:010"=1'0" • For Production/For Presentation IC A1 qPECT:314-REVERSE-LIT INTERNALLY ILLUMINATED PLASTIC FACE CHANNEL LETTERS 3" ' .063"ALUMINUM PRIMARY ELECTRICAL 3"RETURN (NEC 600-5)SEE ELEC.NOTES QUANTITY: ONE(1) .080°ALUMINUM j Overall Height: 3.75' 4 Overall Length: 16'-0" LED ALUMINUM ENCLOSURE Total Sq.Ft.: 60 ft' PLOT PLANS .19"CLEAR LEXANTM Returns: Bronze Color - Backs: Bronze Color CHECKED E1Y LISTED BUSHING LED POWER SUPPLY Trimcap: Bronze 7 1 J Face: Bronze and Sign White 1p�1TE SPACER FASTENERS AS First-surface translucent vinyl: Digital Print REO'D.BY LOCAL Illumination: JT White LED's JURISDICTION PILANNIN Iia"DRAIN HOLES L L�t3EL i}S R.EQ•D N.T.S. LISTED DATE •Individually Mounted • •WHITE interiors for increased illumination Power -by a licensed electrical contractor or licensed - •All paint two-stage automotive acrylic lfi't.DG. Dt�RR Each sign must have 1.A minimum of one dedicated 120V 20AcircHit 2.Junction box installed%vithin 6 feet of • 3.Three wires�Line,Ground.Neutral • • • - • • Client Name: Start Date: 10/03/2011 Sales Rep: Cupertino Oral Surgery Last Revision: 00/00/0000 -------------------------------------------- Name • ' • • • Job#: 00000 Client Approval Designer: Location: Drawing#: 00000a.vl.sl/el Steve K Coulthard Civic Park,Cupertino,CA • ------------------------------------------- UMBER • r • ' Page: 1 of 2 Landlord Approval ❑0 ® LISTED IN PART OR WHOLE WITHOUT WRITTEN PERMISSION ©COPYRIGHT 2011,BYAMCOE SIGN CO•ALL DESIGNS PRESENTED ARE THE SOLE PROPERTY OF AMCOE SIGN CO,AND MAY NOT BE REPRODUCEDS 0. ' Length Sign • i4 AV LH- 1 I [11[ lilt[-T , - = - NT.T., CUPERTINO p 1 2011 : . RM pE � LiL____jL_1'11 �o L 1 11 1�111 • • Identity • • Client Name: Start Date: 1010312011 Sales Rep: Cupertino Oral Surgery Last Revision: 00/00/0000 -------------------------------------------- Name Amcoe Sign CompanyJob#: 00000 Client Approval Designer: Location: Drawing#: 00000a.v1.s1/e1 Steve K Coulthard lei 65n-858-1221 I Fox 650-85�-'_M Civic Park,Cupertino,CA •------------------------------------------- usrED Page: 1 of 2 Landlord Approval 0 .�... Q COPYRIGHT 2011,BYAMCOE SIGN CO-ALL DESIGNS PRESENTED ARE THE SOLE PROPERTY OF AMCOE SIGN CO,AND MAY NOT BE REPRODUCED IN PART OR WHOLE WITHOUT WRITTEN PERMISSION FROM AMCOE SIGN CO. Made Sion - Cupertino - CA TENANT BLADE SIGN PURPOSE: g" Tenant identification at pedestrian scale. REFERENCES: Title 17, Cupertino Municipal Code. All sign drawings submitted to the City for a Sign Permit shall include the Landlord's approval of all proposed sign designs. LIGHT _ BLADE SIGN GUIDELINES BRACKET Ll NUMBER OF SIGNS: One (1) sign per tenant storefront. Corner tenants may ave one (I) sign per storefront SIGN frontage. 2--10" SIGN: 71 Aluminum frame powder coated black to match bracket. Sign frame shape may vary within a maximum of 7 s.f. per side. Tenants are encouraged to use variable surfaces, finishes colors; and material thicknesses, in their sign face. LIGHTING: 2`6" Low voltage 'BK LIGHTING Twin Sign Star – C in black finish. BRACKET: Tenant shall design a custom formed, wrought iron bracket and wall plate. • ���� Finish shall be black powder coat with an eggshell finish, SIGN PLACEMENT: — Center sign on a column / wall pier nearest the primary storefront entry. A minimum 2'-6" clear height of 8"6" from the sidewalk to the bottom of the blade sign shall be maintained. The top of the bracket plate is suggested to be mounted at 13'6" above the sidewalk. I ELEVATION: END ELEVATION (FACE) 3/4'= ID" 3/4'= I'O' • • • , • • Client Name: Start Date: 1010312011 Sales Rep: CupeRinoOral Surgery Last Revision: 00100/0000 -------------------------------------------- Name • ' • • • • Job#: 00000 Client Approval Designer: Location: Drawing#: 00000a.vl.sl/el Steve K Coulthard Civic Park,Cupertino,CA •------------------------------------------- NEMS t1STED Page: 1 of 2 Landlord Approval 044 0 Q COPYRIGHT 2011,BY AMCOE SIGN CO•ALL DESIGNS PRESENTED ARE THE SOLE PROPERTY OF AMCOE SIGN CO.AND MAV NOT BE REPRODUCED IN PART OR WHOLE WITHOUT WRITTEN PERMISSION FROM AMCOE SIGN CO. Certificate of Compliance (Sign Lighting) (Page 1 of 4) SLTG-1C Project Name: I err,AJ6 OJ�In�L TU)26-<-12 V+ M7VW mlp Date: i Project Address: 9-a-5-3a W60MGCAI�R5e d,9Wr Location of Sign VDutdoor Signs ❑Indoor Signs Phase of Sign Construction ❑New Signs ❑Sign Alterations Type of Lighting Control ❑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) ❑Maximum Allowed Lighting Power ❑ Specific Lighting Sources 1. Certificate of Compliance Declaration Statement(this may be a C 10,C45 or other eligible person) CY- I certify under penalty of perjury,under the laws of the State of California,the information provided on this form is true and correct. IV I am eligible under Division 3 of the California Business and Professions Code to accept responsibility for the lighting design. This Certificate of Compliance identifies the lighting features and performance specifications required for compliance with Title 24,Parts I and 6 of the California Code of Regulations. The design features represented on this Certificate of Compliance are consistent with the information provided to document this design on the other applicable compliance forms,worksheets,calculations,plans and specifications submitted to the enforcement agency for approval with this building permit application. Name: v Signature �JEN Cv �-�-� Compagy: DeWT7 1 Mc CSJ &N Phon Address: �-! n�� Licen number(may be contractor's lic#) -! W T22"&o- 76 a 8 q,,,' City/State/Zip: Date FR,C-'-M6AJ7- 9ZfS3Co /1 a 2. Installation Certificate(to be signed by responsible person after installation) Permit number Checked by/Date IEnforcement Agency Use) forcement Agency Use Installation Declaration statement U I certify under penalty of perjury,under the laws of the State of California,the information provided on this form is true and correct. I am eligible under Division 3 of the Business and Professions Code to accept responsibility for construction,or an authorized representative of the person responsible for construction. U I certify that the installed features,materials,components,or manufactured devices identified on this certificate conforms to all applicable codes and regulations,and the installation is consistent with the plans and specifications approved by the enforcement agency. F.1 I certify that the requirements detailed on this Certificate of Compliance have been met. - I will ensure that a completed,signed copy of this Installation Certificate 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 understa that a signed copy of this Installation Certificate is required to be included with the documentation the builder provide" rovide e building owner at occupancy. y Company Name: Responsible Person's Name: tO esponsible Person's Signature: f: License number(may be contractor's lic#) Date Si tied: m osition With Company: n O O 2008 Nonresidential Compliance Forms yP October 2010 w ! r Certificate of Compliance (Sign Lighting) (Page 2 of 4 SLTG-1C Project Name Date: GuioCP-V n10 pP ffL 4- behrmL ll►tiPI&JTS 1 112 ,111 3. 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. !f 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 or the entire construction. 3a. Statements of Responsibility: Any person signing the Certificate of Compliance Declaration Statement on page l of 4 on this SLTG-1 C shall complete Part 3a.Check Yes or No for all of the following statements: I I have responsibility for installing the sign lighting controls 4-Yes,complete parts 3a and 3b of this form ❑No,complete part 3a of this form 2 There are no existing sign lighting controls and I will be installing compliant sign lighting controls Yes ❑No 3 There are no existing sign lighting controls and someone else will be responsible to install compliant sign lighting controls ❑ Yes �jNo There are existing sign lighting controls that do not comply with the applicable provision of§119 and§133 and I will be 4 installing compliant sign lighting controls ❑ Yes bdNo There are existing sign lighting controls that do not comply with the applicable provision of§119 and§133 and someone else 5 will be responsible to install compliant sign lighting controls ❑ Yes �(No 3b. Mandatory Sign Lighting Controls If the person signing the Certificate of Compliance Declaration Statement on page 1 of 4 of this SLTG-1 C 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 rIndato measures si n li tin control note block can be located: §133(a)l.All indoor sign lighting is controlled with an automatic time switch control that complies with the Y N NA a licable re uirements of 1 l9. 11 11ts §133(a)l and 2. All outdoor sign lighting is controlled with an automatic time switch control plus a photo Y N NA control,or an outdoor astronomical time switch,that comply with the applicable requirements of§119. z ❑ ❑ Exception to§133(a)2. Outdoor signs in tunnels or large covered areas that require illumination during Y NA daylight hours. ❑ ❑ §133(a)3. All outdoor signs are controlled with a dimmer that provides the ability to automatically reduce Y N NA sin power by a minimum of 65 percent during nighttime hours. ❑ ❑ ❑ Exception 1 to§133(a)3.Signs illuminated for less than one hour per day during daylight hours. Y NA 3 EL 1 ❑ Exception 2 to§133(a)3. Outdoor signs in tunnels or large covered areas that require illumination during Y NA daylight hours. ❑ ❑ Exception 3 to§133(a)3.Only metal halide,high pressure sodium,cold cathode,or neon lamps used for Y NA illuminating signs or parts of signs. ❑ ❑ §133(a)4. An Electronic Message Center(EMC)having a new connected lighting power load greater than Y N N/A 15 kW has a control installed capable of reducing the lighting power by a minimum of 30 percent when ❑ ❑ 4 receiving a demand response signal that is sent out by the local utility. Exception to§133(a)4.EMC required by a health or life safety statue,ordinance,or regulation,including Y NA but not limited to exit signs and traffic signs. ❑ Q Field Inspector Notes: 2008 Nonresidential Compliance Forms October 2010 Certificate of Compliance (Sign Lighting) Pa 3,e 3 of 4 SLTG-1C Project Neste:^A Date: oot�St 4. Maximum Allowed Lightinir 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 5 of this Certificate of Compliance if there are signs using the S ecific lialiting sources method of com liance A B C D E I FG H I J o Allowed Watts Design Complies? Watts Y/N o > a� w U °o 0 — Q � N- V1 W o z '� w 1� ?,-" 0 3 " `= a .0 E ' 3 � N � Field Q y z E _ u u o ii Inspector rn o w ¢ w Check that E ¢ U Sign o 0 Complies Description ✓ Ij-L- CI-fEi-�unJEL [etrf--�eg ON l5u t L.�D t nl Cr ❑ ❑ 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. 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 148 of the California 2008 Title 24,Part 6 Standards,using the Maximum Allowed Lighting Power method of compliance. The only labels that will be recognized for this purpose arc ENERGY VERIFIED Certification Marks authorized C 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`1'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. LF The si n area insquare feet. List"I"if the si n is internal) illuminated. List"E"if the si is external) illuminated. Allowed watts er s uare foot. Enter 12 if the si n is listed as"I"in column E.Enter 2.3 if si n is listed as"E"in column E. Multi 1 the uare foota a in column D times the allowed Li htin Power Densi LPD=watts in column F. Show the total installed watts in the si as determined accordin to thea licable rovisions of 130 d ore . Enter Y if the number in column H is less than orequal to the number in column G. Otherwise the signdoes not comply. This page doubles as a field inspection checklist. Field Inspector Notes: 2008 Nonresidential Compliance Forms October 2010 Certificate of Compliance (Sign Lighting) (Page 4 of 4 SLTG-1C Project Name: Date: N P_/3"I, St1�'�9 t Del I M L PLA mU 1l '79- r l l 5. 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 4 of this Certificate of Compliance if there are signs using the maximum allowed lighting ower method of compliance) A B C D E OPTIONAL Field ENERGY Specific light source used for Inspector Symbol VERIFIED compliance Check that or Description label Shall include only lighting Sign Code (see instructions technologies listed below Complies below) List all that apply ON "ptJlt,DrnlCr 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 buildin •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 148 of the California 2008 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 I through 10 that apply in column D above for each row. I High pressure sodium lamps 2 Pulse start or ceramic metal halide lams served by a ballast with >88%efficient 3 Pulse start metal halide lamps that are<320 watts,are not 250 watt or 175 watt lamps,and are served by a ballast with> 80%efficient 4 Neon or cold cathode lamps with transformer or power supply efficient > 75%with rated output current<50 mA 5 Neon or cold cathode lamps with transformer or power supply efficient > 68%with rated output current>_50 mA Fluorescent lamps with a minimum color rendering index(CRI)of 80 6 (Note:when using electronic ballasts for compliance,lamps with a CRI<80 may be used 7 Light emitting diodes LEDs with a power supply with> 80%efficient Single voltage LED external power supplies designed to convert 120 volt AC input into lower voltage DC or AC 8 output,having a nameplate output power less than or equal to 250 watts,and certified to the Energy Commission as complying 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 10 Electronic ballasts with a fundamental output frequency>20 kHz E This page doubles as a field inspection checklist. Field Inspector Notes: 2008 Nonresidential Compliance Forms October 2010