15120120CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19700 VALLCO PKWY
; a 3 PERMIT NO: 15120120
tONTRACTOR.&�
� _ --TjE Q1QAF,141 CS
OWNER'S NAME: CUPERTINO PROPERTY DEVELOPMENT I
�,g
W " WPAZ CrDATE ISSUED: 12/14/2015
OWNER'S PHONE: 4083431088
q4= PHONE NO: 0 1�
❑ LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL
License Class—ca--q—!' Lic. #_
STE 160 - "VITALITY BOWLS" - INSTALL (N) ELECTRIC
WALL SIGN ON FRONT EXTERIOR
Contractor �� ate 2 , Sr 000-
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
mation, as provided for by Section 3700 of the Labor Code; for the
nce of the work for which this permit is issued.
jlo�a�d
Sq. Ft Floor Area:
Valuation: $2500
will maintain Worker's Compensation Insurance, as for by
provided
Section 3700 of the Labor Code, for the performance of the work for which this
-
APN Number: 31620108.19700
Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating
PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction, and hereby authorize representatives of this city to enter
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
upon the above mentioned property for inspection purposes, (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities judgments,
costs, and expenses which may accrue against said City in consequence of the
180 D YS FROM LAST CALLED INSP CT ON.
4 ) rr
granting of this permit. Additionally, the applicant understands and will comply
tib 6s��'
Issued by: is Date: !�
with all non-point source regulations per the Cupertino Municipal Code, Section
9.18.
j
Signature Date
RE-ROOFS:
f
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
I hereby affirm that I am exempt from the Contractor's' License Law for one of
Signature of Applicant: Date:
the following two reasons:
I, as owner of the property,, or my employees with wages as their sole compensation,
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
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
I hereby affirm under..penalty of perjury one of the following three
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's
Health & Safety Code, Section 25532(a) should I store or handle hazardous
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, Sections 25505, 25543, and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
1
permit is issued.
Owner or authorized agent- Date:
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
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
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
SIGN PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CU'PERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • buildina a'7cupertino ori
pan "'10—
PROJECT
PROJECT ADDRESS �� f
APN #
l j
OWNER NAME
I�_!
f!*O [ Algwft PxnN � E -MA
naec -.
STREETAPnCI E. FAX
CONTACT NA PH NE
STREET ADDRESS CIT •, STATE, ZIP.��_ FAX
-���t .r e
❑ OWNER ❑ OWNER-BUIIAER ❑ OWNER AGENT 0 CONTRACTOR CONTRACTOR. AGENT- ❑ ARCHITECTS ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
C,PNTRACTOR NAM ' LI NSE N MBE
% ®
LICE6 TYPE -
BUS. LIC #
MPA NAME
c
E -MA
FAX
STREET ADDRESS p�� ®
C . , STATE, ZIP m
P
ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK
USE OF ❑ SFD or Duplex ❑ Multi -Family
STRUCTURE: ❑ Commercial
ILLUMINATED
SIGN TYPE
NO. OF
SIGN AREA
VALUATION
(Y/
(CODE)
SIGNS
(SQ: FT.)
($)
SIGN TYPE CODES:
d
;7
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 WI -WINDOW SIGN
RECEIVED BY:
i
�r
TOTAL VALUATION:
By my signature below, 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
application and the information I have provided is correct. I have read the Description of Wort: and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building- construction. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes.
Signature of AppiicantlAgent: se Date:
SUPPLEMENTAL INFORMATION REQUIRED
OFFICE USE ONLY
PLAN CHECK TYPE
ROUTING SLIP
_ Site Plan
Elevations
OVER-THE-COUNTER
❑ BUILDING PLAN REVIEW
Sign Details - including UL listing(s) applicable
❑ EXPRESS
❑ PLANNING PLAN REVIEW
_ Structural Calculations (if applicable)
❑ STANDARD
❑ OTHER. -
Copy of Planning Approval Letter or Meeting with Planning prior to
❑ LARGE
submittal of Building Permit application.
❑ MAJOR
SignApp 2011:doc revised 03/31/11
CITY OF CUPERTINO 1 l ac) l
FEE ESTIMATOR - BUILDING DIVISION
w ADDRESS: 19700 Vallco Parkway STE #160 DATE: 12/14/2015 REVIEWED BY: PAUL
APN: 316 20 108 BP#; *VALUATION: 12,500
*PERMIT TYPE: Building Permit
PRIMARY PENTAMATION
USE: Sign PERMIT TYPE: 10EAP5
WORK Ste 160 - "Vitality Bowls" - Install (N) electric wall sign on front exterior
SCOPE
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 based on the preliminary information available and are only an estimate. Contact the Deptjor aaan't anfo.
FEE ITEMS (Fee Resohition 11-053 Eff 7/U13)
FEE
QTY/FEE
MISC ITEMS
Plan CIrFrc
Suppl. PC Fee: Reg. 0 OT
O.Q ;'
hrs
$0.00
# Branch Circuits
1
$48.00
Permit Fee:
$286-.00
Suppl. Insp. Fee:E Reg. 0 OT
1 0.0
hrs
$0.00
IESIGN
PME Unit Fee:
$48.00
PME Permit Fee:
$48.00
Elec. Permit Fee: IEPERMIT
^ztfinl}'Zistra,li ' ee.
Work Without Permit? 0 Yes No
$0.00
Sign Master Plan: O Yes (2) No
tr ;: ,>
i
Travel Documentation Fee: 1TRAVDOC
$48.00
Strong Motion Fee: 1BSEISMICO
Other Elec. Insp.
0.0
Bldg Stds Commission Fee: IBCBSC
$48.00
Su�TOTALs .
$431.70
$0.00 TOTAL FEE :
$431.70
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 based on the preliminary information available and are only an estimate. Contact the Deptjor aaan't anfo.
FEE ITEMS (Fee Resohition 11-053 Eff 7/U13)
FEE
QTY/FEE
MISC ITEMS
Plan CIrFrc
Suppl. PC Fee: Reg. 0 OT
O.Q ;'
hrs
$0.00
Permit Fee:
$286-.00
Suppl. Insp. Fee:E Reg. 0 OT
1 0.0
hrs
$0.00
PME Unit Fee:
$48.00
PME Permit Fee:
$48.00
^ztfinl}'Zistra,li ' ee.
Work Without Permit? 0 Yes No
$0.00
Sign Master Plan: O Yes (2) No
$0.00
i
Travel Documentation Fee: 1TRAVDOC
$48.00
Strong Motion Fee: 1BSEISMICO
$0.70
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
Su�TOTALs .
$431.70
$0.00 TOTAL FEE :
$431.70
Revised: 10/01/2015
OFFICE COP`
BOWLS
bi
li WN'1 If ti L'r' , : L `,
PROPOSED SIGNAGE kale: 1/2(S)'=V
13r0l')
"'Tr) FCUPERTINO 714,
Building Department
DEC
I
REVIEWED FOI CODE �OQVPLIANCE
lY
IN
job site during coni
Corporate
PRO
Graphics
Rl'i
iunor0, t A 97510
4+921933 /45/
Fax'915..Y /441
FACE MATERIAL PLEX.
WWW.(,��H.t..NW ♦rnn
:.
License 08 11422
__..
V.
1. TRIM CAP WITH RETAINING SCREW
2. PLEX FACE, VINYL FIRST SURFACE
3. L.E.D.
4. ALUMINUM.063'BACKS/.040'RETURN
S. WIREWAY
6. POWER SUPPLY
7. FASTENERS AS NEEDED
B. WALL
NT
JECT LOCATION REVISIONIDATE
ail Sign 19700VallcoParkway 4160 i4A
'rlr7 of this -' Cupertino, CA95014 rly,ns SHALL NOT
408-564-4585
LO
per nit o L,_ _ . val of the violation
n
provisions of any City Ordinance or Siate Law.
Jj/�'aE �Sll.(.UV�tI�
I I �CJIo1O ,
J�• o
RECEIVED
BOV1Wl� ...
13Y
0
SPECIFICATIONS
BOWLS
DESCRIPTION
FRONT -LIT CHANNEL LETTERS MOUNTED TO WMEWAY.
LETTERS
MATERIAL CHANNEL
FACE MATERIAL PLEX.
COLOR WHITE
OTHER VINYL FIRST SURFACE AS SHOWN.
RETURNS COLOR WHITE
OEM S.
TRW W WHITE
ILLUMINATION LED. ALL LETTERS INDIVIDUALLY LR.
MOUNTING MOUNTEDTOCABINET
CABINET
MATERIAL 1/4'ALUMINUM.
COLOR PAINTED AND TEXTURED TO MATCH BUILDING.
DEPTH YPERREOUIREMENT.
MOUNTING FLUSH -MOUNTED TO WALL SURFACE.
FILE INFORMATION
Contact:
Address: PL�/'J�
Drawn By lames Woods Marsha , lam oodsmarsh I.
File Location: cg/vb
Scale: As Shown.
DATE,-'
PUNNING DEI
CUPERTINO
STATE OF CALIFORNIA
CERTIFICATE OF COMPLIANCE, SIGN LIGHTING
CEC-SLTG-1C (Revised 10/10) CALIFORNIA ENERGY COMMISSION
Certificate of Compliance
(Sign Lighting)
(Page 1 of 4) SLTG-1C
Project Name:
• This Certificate of Compliance identifies the lighting features and performance specifications required for compliance with
Date: � � � � �
Project Address:
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:
Signature
-
Company:
GLw—
Location of Sigh
❑ Outdoor Signs ❑ Ind or Signs
License number (may be contractor's lic #)
Phase of Sign Construction
❑ New Signs ❑ Sign Alterations
City/State Zip: _
Type of Lighting Control
❑ New Lighting Controls ❑ Replaced Li hting 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 C10, C45 or other eligible person)
• I certify under penalty of perjury, under the laws of th t iF r' ifaamia.AU"nfhrmatj011 prox i c4W form is true and
correct.
• I am eligible under Division 3 of the California an Pro ss se 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 1 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:
Signature
-
Company:
GLw—
enforcement agency.
Address:
License number (may be contractor's lic #)
3
C .f- ' z
City/State Zip: _
Date
2. Installation Certificate (to be signed by responsible person after installation)
Permit number
Checked by/Date
(Enforcement Agency Use
(Enforcement Agency Use
Installation Declaration statement
• 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.
• 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.
• 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�� �t uilding
permit(s) issued for the building, and made available to the enforcement agency for all apph rstand
that a signed copy of this Installation Certificate is required to be included with the documentation the builder provides to the
building owner at occupancy.
Company Name:
Responsible Person's Name: Responsible P n's Signature: By
License number (may be contractor's lic #)
Date S coed Position With Company:
2008 Nonresidential Compliance Forms October 2010
STATE OF CALIFORNIA
CERTIFICATE OF COMPLIANCE, SIGN LIGHTING x
CEC-SLTG-1C (Revised 10/10) CALIFORNIA ENERGY COMMISSION
Certificate of Compliance (Sign Lighting) (Page 2 of 4) SLTG-1C
Project Name:
Date
3. Mandatory Sign Lighting Controls
NOTES.-
OTES.1.
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 or the entire construction.
3a. Statements of Responsibility: Any person signing the Certificate of Compliance Declaration Statement on page 1 of
4 on this SLTG-1C shall complete Part 3a. Check Yes or No for all of the following statements:
1
I have responsibility for installing the sign lighting controls
§133(a)l and 2. All outdoor sign lighting is controlled with an automatic time switch control plus a photo
❑ Yes, complete parts 3a and 3b of this form 1KNo, complete part 3a of this form
N
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
AtTes ❑ No
Exception to §133(a)2. Outdoor signs in tunnels or large covered areas that require illumination during
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
daylight hours.
❑ Yes ❑ No
❑
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
N
❑ 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-1C 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:
§133(a)1. All indoor sign lighting is controlled with an automatic time switch control that complies with the
Y
N
NA
1
applicable requirements of § 119.
❑
❑
❑
§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
sign ower by a minimum of 65 percent during nighttime hours.
❑
❑
❑
Exception 1 to§133(a)3. Si s illuminated for less than one hour per da during daylight hours.
P� P Y g❑
Y
NA
❑
3
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
illumigns 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.
❑
❑
Field Inspector Notes:
2008 Nonresidential Compliance Forms October 2010
STATE OF CALIFORNIA
CERTIFICATE OF COMPLIANCE, SIGN LIGHTING
CEC-SLTG-1C (Revised 10/10) CALIFORNIA ENERGY COMMISSION
Certificate of Compliance (Sign Lighting) (Page 3 of 4) SLTG-IC
Project Name: Date:
4. 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 5
of this Certificate of Compliance if there are si ns using the S ecific lighting sources method of compliance)
A
B
C
D E I F G
H
I
.l
o
Allowed Watts
Design
Complies?
w
Watts
Y / N
w
Field
_
3
x
Inspector
Check that
o
z
w
a 3
w
3
b
!tSign
.$
.a ,c
�
0
� � �
3 � N
� Q
°' •�"
Complies
Z N
° II
o II
a
o
✓
c =°
o
Description
❑
❑
❑
❑
❑
❑
❑
❑
❑
❑
❑
El
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 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
C
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 insquare 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(d ore .
I
Enter Y if the number in column H is less than orequal to the number in column G. Otherwise, the sign does not comply.
J
This page doubles as a field inspection checklist.
Field Inspector Notes:
2008 Nonresidential Compliance Forms October 2010
STATE OF CALIFORNIA
CERTIFICATE OF COMPLIANCE, SIGN LIGHTING ;#
CEC-SLTG-1C (Revised 10/10) CALIFORNIA ENERGY COMMISSION
Certificate of Com fiance (Sign Lighting) (Page 4 of 4) SLTGIC
Project Name:
Date:
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
❑
❑
❑
❑
.1
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 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 (1 through 10) that apply in column D above for each row.
1
High pressure sodium lamps
2
Pulse start or ceramic metal halide lamps served by a ballast with > 88% efficient
Pulse start metal halide lamps that are:5 320 watts, are not 250 watt or 175 watt lamps, and are served by a ballast
3
with > 80% efficient
4
Neon or cold cathode lamps with transformer or power supply efficient > 75% with rated output current < 50 MA
S
Neon or cold cathode lamps with transformer or power supply efficient > 68% with rated output current > 50 MA
D
6
Fluorescent lamps with a minimum color rendering index (CRI) of 80
(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
comp1ying 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 Fornns October 2010