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14120017 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20080 STEVENS CREEK BLVD CONTRACTOR:YERGLER PERMIT NO: 14120017 CONSTRUCITON CO INC OWNER'S NAME: PREG BILTMORE 9134 LOCUST ST DATE ISSUED:03/10/2015 OWNER'S PHONE: 9495334117 ELK GROVE,CA 95624 PHONE NO:(916)417-4541 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL E] COMMERCIAL E] C /_ STE 106-TENANT IMPROVEMENT FOR FRESH PIXX(2800 License Class Lic.# //(� > SQFT) Contractor ` C G L �V atc�70 t_ `�;� REVISION#2:REVISE KITCHEN CEILING; KITCHEN LAYOUT; AND REVISE TOILET STALL CONFIGURATION. I hereby affirm that I am licensed under the provisions of Chapter 9 -ISSUED 5/7/15 (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: 1 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 rflormance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$100000 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 APN Number:36903009.20080 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. 1 agree to comply with all city and county ordinances and state laws relating WITHIN 180 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 A LED 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 S/� granting of this permit. Additionally, applicant understands and will comply te: 000, with all non- sourc ulations pe a Cupertino Municipal Code,S on 9.18. + RE-ROOFS: Signature Date 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: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 1,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) 1,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 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 I 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 t upertino Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,S 550 , 3,and 34. Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. j`; Owner or authorized agent._ Date: 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 1 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 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 BUILDING PERMIT BUILDING ADDRESS: 20080 STEVENS CREEK BLVD CONTRACTOR:YERGLER PERMIT NO: 14120017 CONSTRUCITON CO INC OWNER'S NAME: PREG BILTMORE 9134 LOCUST ST DATE ISSUED:03/10/2015 OWNER'S PHONE: 9495334117 ELK GROVE,CA 95624 PHONE NO:(916)4174541 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL E] COMMERCIAL a� STE 106-TENANT IMPROVEMENT FOR FRESH PIXX(2800 License Class_ Lic.# c> t 6 5 SQFT) Contractor , ate — I hereby affirm tha I am licensed under the provisions of Chapter 9 3/30/15-REV#1-COVER(E)WALL LOUVERS FROM THE INSIDE-ISSD (commencing with Section 7000)of Division 3 of the Business&Professions OTC 4/8/20I5 Code and that my license is in full force and effect. 1 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. Sq.Ft Floor Area: Valuation:$100000 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 APN Number:36903009.20080 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 F 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 FRr T CALLED INSPE T ON* indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the P granting of this permit. Additionally,the app'cant understands and will comply Issued by: Date: 0 with all non-point source regul 'ons per the ertino Municipal Code,Section 9.18. RE-ROOFS: Signature Date 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 1 hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date: 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) 1,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 I 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 1 have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sectio 5505 25533,Oil 25534. Section 3700 of the Labor Code,for the performance of the work for which this A-2)—v5- 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 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 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20080 STEVENS CREEK BLVD CONTRACTOR:YERGLER PERMIT NO: 14120017 CONSTRUCITON CO INC OWNER'S NAME: PREG BILTMORE 9134 LOCUST ST DATE ISSUED:03/10/2015 OWNER'S PHONE: 9495334117 ELK GROVE,CA 95624 PHONE NO:(916)417-4541 JOB DESCRIPTION:RESIDENTIAL COMMERCIAL LICENSED CONTRACTOR'S DECLARATION TENANT IMPROVEMENT(SUITE 106)FOR FRESH License Class Lic.# S� ^�d (2800 SQ FT. Contractor Z.- L C04-_S71e.CO Date 3 1 S I hereby Arm 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 If ompensation,as provided for by Section 3700 of the Labor Code,for the erformance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$100000 d 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:36903009.20080 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 DAYSCALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, 7�,IRT costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply Issued by: Date:✓'/ with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. RE-ROOFS: Signature Date 3r//o//C 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. ❑ OWN -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: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 1,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) 1,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 I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.I2 and the declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous I 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 Cu rtino Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 2 ' ,25533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date: 3 hO S 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 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 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 CONSTRUCTION PERMIT APPLICATION (,(� COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 112 0 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 GUPERTIND (408)777-3228 • FAX(408)777-3333•building C�CUpertino.orq ❑NEW CONSTRUCTION ❑ ADDITION ALTERATION/TI ❑ REVISION/DEPE/RRED ORIGINAL PERMIT# PROJECT ADDRESS �ooBO S! (DO APN>= 03 —Ooq OWNER NAME slf�' PHONEfj V E-MAIL t �r ^ STREET ADDRESS OD S-Q k,)(- r /_ f� CITY, STA D FA.X CONTACT NAME ( krw PHONE '`13— f E-,LL0. (q C P1,Q J r. O STREET ADDRESS d CITY,.n,B,Zt ' FAX i•• ❑OWNER ❑ OWNER-BUILDER ❑ OWNER.AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT IN ARCHITECT AENGINEER ❑ DEVELOPER ❑TENANT CONTRACTORNAME /V LICENSE NUMBER LICENSE TYPE BUS.LIC* COMPANY NAME �j E-MAIL FAX STREET ADDRESS CITY,STATE.,71P PHONE ARCHITECTr'ENGINEERNAMI QV jA LICENSF.NUMBER n,� BUS LICK COMPANY NAMG V -btA[L I ,�j-vt C ( ` C4*A FAX STREET ADDRES� FS-7, s'1 CITY,STATE,ZIP �l PHO; DESCRIPTION OF WORK / �i d 66K e Vk ! � W \ VLt EXISTINGUSE PROPOSED LSE CON TYPE STORIES V / USE TYPE OCC. SQ.Fr. VALUATION(S) EXISTG NEW FLOOR DEMO r TOTAL l AREA AREA AREA NETAREA �I ROa KeAvIvIt -1 / `7 j,�f�Q /0/dp0�- BATHR M V KITCHEN OTHER ` f.� T s�^s - t REMODEL AREA REMODEL,AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK11OR11I AREA GARAGE AREA DETACH []ATTACK s DWELLING UNITS. IS A SECOND UNIT []YES SECOIrD STORY ❑YES BEINGADDED7 C]NO ADDITION' ❑NO PRE-APPLICATION OYES IF YES,PROVIDE COPY OF ISTHEBLDGAN ❑YES RECEIVED BY: TOTAL VALUATION: PLANNING APA.# RIO PLANNING APPROVAL LETTER EICHLER HOME, +r l 0 160, 000 By m)signature below,I certify to each of the following, I am the property owner or authorized agent to t on the roperty owner's behalf. I have read this app]ication and the information I have provided is correct. I have read the Description of Work and verify it Is accurate. I aeree to comply with all applicable local ordinances and state laws relating to building constnjja4i. I authorize representatives of Cupertino to enter the above-identified pro rty for inspection purposes. Signature of Applicant/Agent: Date: SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECK TYPE ROUTING SLIP New SFD or Multifamily dwellings: Apply for demolition permit for ❑ OVER-THE-COUNTER ❑ BUILDING PLAN REVIEW existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUBLIC WORKS foml if any Hazardous Materials are being used as part of this project ❑ LARGE ❑ FIRE DEPT Copy of Planning Approval Letter Or Meeting with Planning prior t0 ❑ MAJOR ❑ SAN ITARYSEWER DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH B&gAPp_20l I-doc revised 06.21,11 CONSTRUCTION PERMIT APPLICATION COMMUNITY 10300 TORRE AVENUCWF�RTIN3T &A 10300 DIVISION CUPERTfNO (408)777-3228• FAX (408)777-3333 •buildino(d)cupertinno.org ❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI REVISION/DEFERRED ORIGINAL PERMIT# PROJECT ADDRESS APN k OWNERNAME �;� PHONE MAIL e,& STREET ADDRESS I D LA� �.• 1 CTTY, STATE,ZIP TT FAX CONTACT NAME Tr W ;ev PH _ .. ��� E-MAIL 1 l'r iAn STREET ADDRESS CITY,STATE, ZIP FAX OWNER ❑ OIaINER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAMLICEN N ER LICENSE TYPE BUS.LIC 9 COMPANY NAME E-MAILI�{r, FAX uer(a STREET ADDRESSI C STA E,ZIP NE ARCHITECT/E EER 'AMELICENSE NUMBER G- BUS.LIC# COMPANY NAMF E-MAIL, r' DA.,t FAX r yt" STREET E CITY,SAT IP 01%. ^-l� DES*ZZOF V ORK • -ty)i • reii V Com, Al2 EXISTING USE PROPOSEEF USE CONSTR.TYPE #STORIES USE TYPE OCC. SQ.FT. VALUATION(5) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NETAREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK ARE TOTAL DECKTORCH AREA GARAGE AREA: DETACH ❑ATTACH T DWELLING UNITS: 1S A SECOND UNrr ❑YES SECOND STORY ❑YES BEING AD DED? 13 NO ADDITION? NO PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑IBS RECEIVED - TOTALUA ION: PLANNING ADPL 9 ❑NO PLANNING APPROVAL LETTER EICHLER HOME? ❑NO5 By my signature below,I certify to each of he followinz: I am the erty o Al er or authorized agent to act on the property owner's behalf. I read this application and the information I ha v ed is correct. I haver d t e Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relatin bui i co t c' I e r prese ti s of Cupertino to enter the above-identified property forrection purposes. Signature of Applicant/Agent: Date: SUPPLEMENTAL INFORMA N REQUI PLAN CHECICTYPE Io>ITiNs s IP New SFD or Multifamily dwellings: Apply for demolition permit for [] oVER THE coIJI�TER BUILD�cPLaNREVIEw existing building(s). Demolition permit is required prior to issuance of bui]dmQ -r permit for new building. � EXPRESS fl..'PLArNIivGPLAnREVIEw -= _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure - sTNDnRD ❑ puBLICwoRlcs form if any Hazardous Materials are being used as part of this project. LARGE: - ' FIRE DEPT � 4 t � _Copy of Planning Approval Letter or Meeting with Planning prior to pzAaoR ❑ SANITARY SE'4i'ERDISTRTCT submittal of Building Permit application. �- - - ❑,"ENyIRON1�IENTAL HEALTH_`� BldgApp_201 1.doc revised 06121/11 CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT' BUILDING DIVISION A% EL 10300 TORRE AVENUE'CUPERTINO, CA 95014-3255 LJ CUPERTINO (408)777-3228 • FAX (408)777-3333' building cDcupertino.org ❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI t9 REVISION/DEFERRED ORIGINAL PERMIT# PROJECTADDRESS L ece APN# OWNER NAMEPFQ E-MAIL Jba 1 �� F. '1-2,124 S591a-!%en /Q STREET ADDRESS a W w t Kl CII Y�STATE,ZIP FAX CONTACT NAME PH STREET ADDRESS � � �11 , fA � o FAX CITATE OWNER ❑ OIYNER-BUILDER ❑ OIAIKERAGENT ❑ CONTRACTOR ❑CONTRACTORAGENT ARCHITECT ❑ENGLNEER ❑ DEVELOPER ❑TENANT CONTRA R NAMELIC ' E 41} LICENSE TYPE BUS,LIC 41 COMPA NAME . 0 E-MAIL FAX C1 [eCr STREET ADDCITY,STATE,ZID. PH _ A ARCHITECT/E INEE NAME LICENS %U - BUS.LIC 4 G COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHOT E DESCRIPTION OF WORK Gou�r eoe EXISTING USE PROPOSED USE CONSTR TYPE k STORIES USE TYPE OCC. SQ.FT. VALUATION(S) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: El DETACH []ATTACH m D\YELLING UNITS: ISA SECOND UNIT ❑YES SECOND STORY ❑YES T_ BEING ADDED? NO ADDITION? ❑NO PRE-APPLICATION ❑YES LF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES _ IVED- ,; - TAL VALUATION: PLA.N!�7NG APPL'� ❑NO PLANNING APPROVAL LETTER EICHLER HOME? ❑NOS ._ � _- o HM v, By my signature below,I certify to each of the following: I am the property owner or authorized agent to a tie property owner's behalf. I have read this application and the informatiol ve ovided is coa=t. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws rela to it i tion. I authorize representatives of Cupertino to enter the above-identified operty for inspection purposes. Si-nature ofApplicant/Age1 : Date: SUPPLEM 4ATION REQUIRED PLAN,cI�cxTYPE = _RouTLncsilP ;' k': New SFD or Multifamily dwell s: Apply for demolition permit for OVER T] COU�TER ❑`BIJILD�GPLA3�ItE\�\} existing building(s). Demolition permit is required prior to issuance of building *w permit for new building. #{� EXPRESSO ' #{kms P�SNII�GPLAI�REVIE\1 a... _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure3 sT�NDnRD Q.-PUBLIC\ o�ucs form if any Hazardous Materials are being used as part of this project. - "{10 _ o with Planning prior toCoPY ofPlanning Approval Letter Or Meeting c i c DIAJOR I * flSSI�ITARYSEERDISTRPCT submittal of Building Permit application. Q,.EAVIRON11fEINTAI IIEALTA BldgApp_2011.doc revised 06121111 CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 20080 Stevens Creek Blv DATE: 0412212015 REVIEWED BY: Sean APN: BP#: 'VALUATION: Iso FPERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration /Addition/ Repair PRIMARY Civil/Religious activities PENTAMATION USE• Commercial Building �in BQ zone? 0 Yes Q No PERMIT TYPE: 1 GENCOM WORK Revision#1: Revise kitchen ceiling; revise kitchen layout; revise toilet stall configuration. SCOPE lc Li 'r NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc). Theseees are based on the prelimina information available and are only an estimate. Contact the De t or addn7 info. FEE ITEMS (Fee Resolution 11-053 E' i!1./13} FEE QTY/FEE MISC ITEMS Plan Check Fee: Hourly Only? 0 Yes Q No $0.00 F---27 hours Plan Check, Hourly Suppl. PC Fee: (j) Reg. () OTTO-07 h r s $0.00 $286.00 ISTPLNCK PME Plan Check: $0.00 Permit Fee: Hourly Only? ()Yes Q No $0.00 Suppl. Insp. Fee,0 Reg. Q OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Tax: IBCONSTAXC $0.00 Work Without Permit? 0 Yes (E) No $0.00 Advanced Planning Fee: $0.00 0 hours Inspections Q ISTtNSP i $143.00 Inspection, Hourly Strong Motion Fee: $0.00 Select an Administrative Item Bldg Stds Commission Fee: $0.00 SUBTOTALS: $0.00 $429.00 TOTAL FEE: $429.00 Revised: 04/01/2015 CITY OF CUPERTINO FEE ESTIMATOR— BUILDING DIVISION ADDRESS: 20080 STEVENS CREEK BLVD DATE: 03/30/2015 REVIEWED BY: MELISSA APN: 369 03 009 BP#: 14120017 *VALUATION: Iso %PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/Addition / Repair PRIMARY Civil/Religious activities PENTAMATION USE: Commercial Building in BQ zone? 0 Yes •�No PERMIT TYPE: WORK 3/30/15- REV# 1 - COVER E WALL LOUVERS FROM THE INSIDE SCOPE E3 NOTE. This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc.). Theseees are based on the prelimina information available and are only an estimate. Contact the Dept-for addn'l info. FEE ITEMS (Fee Resolution 11-053 Ef 7/1/13) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 Select a Misc Bldg/Structure Suppl. PC Fee: Q Reg. Q OT 0.0 hrs $0.00 or Element of a Building PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee:Q Reg. Q OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Tax: IBCONSTAXC $0.00 Work Without Permit? Yes E) No $0.00 Advanced Planning Fee: $0.00 Select a Non-Residential 0 Building or Structure Strong Motion Fee: $0.00 F 1 1 # Revisions Bldg Stds Commission Fee: $0.00 $859.00 IREVCOMTI I Tenant Improvement SUBTOTALS: $0.00 $859.00 TOTAL FEE: 7$859.001 Revised: 02/14/2015 CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 2,00000 CL o6 1 DATE: 12/01/2014 REVIEWED BY: Sean APN: 36"f a �� BP#: Z/ O? `VALUATION: 1$100,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement PRIMARY Commercial Building PENTAMATION 1A TI USE: PERMIT TYPE: WORK Restaurant Tenant Improvement 2800 sq ft). SCOPE OCCUPANCY TYPE: TYPE OF FLR AREA PC FEES PC FEE ID BP FEES BP FEE ID CONSTR. s.f. A(Tenant Improvements) II-B,111-B,IV,V-B 2,800 $2,541.27 ]ATIPLNCK $1,564.71 ]ATIINSP TOTALS: 2,800 $2,541.27 $1,564.71 MECH,HOURLY © Yes E) No PLUMB,HOURLY Q Yes Q No ELEC,HOURLY Q Yes Q No LJ I i � I E i NOTE: This estimate does not include fees due to other Departments(L e.Planning,Public Works,Fire,Sanitary Sewer District,School District etc. . Thesefees are based on the prefindna information available and are only an estimate. Contact the Deptfor addn 7 info. FEE ITEMS (Ece Rc°.inlalmn I1-n53E 11 113 FEE QTY/FEE MISC ITEMS Plan Check Fee: $2,541.27 Select a Mise Bldg/Structure Suppl.PC Fee: Q Reg. O OT0.0 hrs $0.00 or Element of a Building PME Plan Check: $0.00 Permit Fee: $1,564.71 Suppl. Insp. Fee:Q Reg. Q OT I-0—.01hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 0 Work Without Permit? © Yes Q No $0.00 0 Advanced Plannint-, I'c_:: $0.00 Select a Non-Residential G) Building or Structure 0 trong Motion Fee: IBSEISMICO $28.00 Select an Administrative Item Bldc Stds Commission Fee: IBCBSC $4.00 SUBTOTALS: 1 $4,137.981 $0.00 TOTAL FEE: F$4,137,981 Revised: 1010112014 RECEIVED MAY 12 2015 Building Department City Of Cupertino 10300 Torre Avenue BY Cupertino,CA 95014-3255 C O P E RT I N O Telephone: 408-777-3228 Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: Pn SZJQ a'j�_ PERMIT# (41X1 OWNER'S NAME: go .� PIZZA- PHONE# 916 '41 AJAt GENERAL CONTRACTOR: Qc BUSINESS LICENSE# ADDRESS: 954 �DcC s o- (p" 5 6A CITY/ZIPCODE: Ate' 9!S74a *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. �'a 4'/ec0ns"/ I am not using any subcontractors: Signature Date 4a)C(b4 Please check applicable subcontractors and complete the following information: V/ SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork 4Gc � 7lL — '3 6'1 Q Cement Finishing Electrical ,A q Excavation / - Fencing Flooring/ Carpeting Linoleum/Wood Glass / Glazing Heating 'eL�--� Insulation &>,4Z7S / 3 ,4- Landscaping N rMm- c'�- q- Lathing �¢ Masonry Painting/Wallpaper 6COZ3 Paving Plastering Plumbing i/ Roofing - 14A- Septic Tank S�S r4- Sheet Metal Sheet Rock Tile Own /C' ontrAftor Signature Date CALGREEN NON-RESIDENTIAL CHECKLIST — MANDATORY ITEMS C,)rv1M(_iNJT.Y DEvELC)PfviP`111? CII(ALCANG OMSiON CUPERTI NO ALBERT SALVADOR, PE C130 BOLCINGOP�ICIAL 10300 71ORREAVE."NL1E -CYER`PNO CA 95014-3255 40,8i 777-3228 - FAX :408 z . Ji.;l 'U 9 Cl CuC'E'i'f oLq PURPOSE: The non-residential provisions of the 2013 CalGreen Code outline planning, design and development methods that include environmentally responsible site selection, building design, building siting and development to protect, restore and enhance the environmental quality of the site and respect the integrity of adjacent properties; establishes the means of conserving water used indoors, outdoors and in wastewater conveyance; outlines means of achieving material conservation and resource efficiency; and outlines means of reducing the quantity of air contaminants. Project Name: Fresh Pixx Pizza and Salad Project Address: 20080 Stevens Creek, Ste. 106 Project Description: Design your own pizza and salad restaurant Instructions: 1. The Owner or the Owner's agent shall employ a licensed professional experienced with the 2013 California Green Building Standards Codes to verify and assure that all required work described herein is properly planned and implemented in the project. 2. The licensed professional, in collaboration with the owner and the design professional shall initial Column 2 of this checklist, sign and date Section 1 -Design Verification at the end of this checklist and have the checklist printed on the approved plans for the project. 3. Prior to final inspection by the Building Department, the licensed professional shall complete Column 3 and sign and date Section 2 - Implementation Verification at the end of this checklist and submit the completed form to the Building Inspector. Column 2 Column 3 MANDATORY FEATURE OR MEASURE Project Verification Requirements CHAPTER 5 — NONRESIDENTIAL MANDATORY MEASURES General Requirements The project meets all the requirements of Divisions 5.101 through 5.508. Division 5.1 PLANNING AND DESIGN Planning and Design -Site Development 5.106.1 Storm water pollution prevention. For projects oil one acre or less. develop a Storm Water Pollution Prevention Plan (SWPPP) that has been designed, specific to its site conforming to the State Stcrm water NPDES Construction Permit or iocal ordinance whichever is stricter as is required for projects over one acre. The plan should cover prevention of soil loss by storm water run-off andior wind erosion, of sedimentation andio- of dust/particulate matter air pokution Page I W'9 &6reen.\on-Res Checklisraocrevised 01 23 14 5,106.4 Bicycle parking. Comoly with Sections 5 106.4 1 and 5.106.4.2: or ❑ ❑ meet local ordinance. whichever is stricter. 5.106.4.1.1 Short-Term bicycle parking. If t',e qual fieri project is anticipated to generate visitor traffic, provide permanently anchored bicycle racks within 200 feet of the visitors entrance readily visible to passers-by. ❑ ❑ for 5 percent of VtSit®r motorized vehicle parking spaces being added.with a mir:imum of one two-bike capacity rack. 5.106.4.1.2 Long-Term bicycle parking. For quaiified buildings with over ❑ ❑ 1C 'tenant-occupants provide secure bicycle parking for 5 percent of tenant vehicle parking spaces being added, with a minimum of one space. 5.106.5.2 Designated parking. Provide designated parking for any combination of low-emittinc, fuel-efficient and carpool/van pool vehicles as ❑ ❑ shown in Table 5 106 5 2 5.106.8 Light pollution reduction. Outdoor lighting systems shall be ❑ ❑ designed and installed to comply with the following 1. The minimum requirarre;;its in the California energy Code -or lighting zones 1 —4 as defined in Chapter 10 of the California Administrative Code, and ❑ ❑ 2 Backlight, Uplight and Gare iBUG) ratings as defined in, IES TM-15-111 and ❑ ❑ 3. Allowable BUG rating not exceeding those shown in Table 5.106 8. or ❑ ❑ Comply with a local ordinance lawfully enacted pursuant to Section 101.7 whichever is more stringent. 5.106.10 Grading and paving. The site shall be planned and developed to keep surface water away from buildings. Construction plans shalt, indicate how ❑ ❑ site grading or a drainage system will manage all surface water flows. Division Performance Requirements 5.201.1 Scope. The California Energy Commission will continue to adopt © ❑ mandatory building standards Divisionf/ CONSERVATION Indoor Water Use 5.303.1 Meters.Separate meters shall be installed for the uses described in Sections 503.1.1 and 503 1.2. 5.303.1.1 New building or additions in excess of 50,000 square feet. El 13Separate submeters shall be installed as follows 1. For each individual leased. rented or other tenant space within the ❑ ❑ budding projected to consume more than 130 gal/day i 2 Where separate submeters are unfeasible, fcr water suppled to the following systems a. Makeup water for cooling towers where flow through is greater ❑ ❑ than 500 gpm. b. Makeup water for evaporative coolers greater than 6 gprn. c Steam and hat-water boilers with energy input > 500,000 Bturri. Paee 2 of9 CalGreen ion-Res Checklisi.doe revised 0123 14 5.303.1.2 Excess consumption,A separate submeter shall be p provided for any tenant within a new building or wither an addition that is protected ❑ ❑ to consume > 1.000 gay/day 5.303.2 Water reduction. Plumb ng fixiures shall meet the maximum flow rate values shown: in Table 5 303.2 3 X❑ ❑ Exception: Budding that demonstrate 20-percent overall water use reduction 5.303.2.1 Areas of addition or alteration. For those occupancies within the authority of the California Building Standards Ccmmission as specified in Section 103. the provisions of Sectior 5.303.2 and Section 5.303 3 shall © ❑ apply to new fixtures in additions or areas of alterations to the buildings. 5.303.4 Wastewater reduction. Each building shall reduce by 20 percent wastewater by one of the following methocs The installation of water-conserving fixtures or ® ❑ 2 UUfzing non-potable water systems. © ❑ 5.303.6 Standards for plumbing fixtures and fittings. Piumbing fixtures ar:d fittings shall be installed in accordance w,th the California Plumbing Code 0 ❑ (CPC) and shall meet the applicable standards referenceo in CPC Table 1401,1 and CalGreen Chapter 6. Outdoor Water Use 5.304.1 Water budget.A water budget shall be developed for landscape ❑ ❑ irrigation use 5.304.2 Outdoor potable water use. For new water service or for addition or alteration requiring upgraded water service for landscaped areas of at least ❑ ❑ 1.000 sq.ft. but not more than 5 000 sq.ft., separate submeters or metering devices shall be installed for outdoor potable water use 5.304.3 Irrigation design. In new nonresidential construction or building addition or alteraton with at least 1,000 but not mr_re than 2,500 sq.ft. cf cumulative landscaped area. install irrigation controllers and sensors which ❑ ❑ include the following criteria. and meet manufacturer's recommendations 5.304.3.1 Irrigation controllers. Automatic irrigation system controllers installed at the time of`inal inspection shall comply with the following 1 Controllers shall be weather- or soil moisture-based controllers that automatically adjust irrigation in response to changes in plants needs as ❑ ❑ weather conditions change. 2. Weather-based controllers without integral rain sensors or communication systems that account for local rainfall shall have a separate wired or wireless rain sensor which connects or communicates ❑ ❑ with the controller(s). Soil moisture-based controllers are not required to have rain sensor input Weather Resistance and Moisture Management 5.407.1 Weather protection. Provide a weather-resistant exterior wail ane foundation envelope as required by California Building Code Section 1403.2 ❑ ❑ and California Energy Code Section 150 manufacturers installation instructions or local ordinance, wnicnever is more stringent ' Pace +of 9 C aIG,ept! \ren-Ross Chveklisr.doc revised 0123/j 5.407.2 Moisture control. Employ moisture cont-ol measures by trio following methods. 5.407.2.1 Sprinklers, Prevent irrigation spray or structures. ❑ ❑ 5.407.2.2 Entries and openings. Design exterior entries and/or openings ❑ ❑ to prevent water intrusion into buildings. 5.407.2.2.1 Exterior door protection, Primary exterior entries shall be covered to prevent water intrusion by using nonabsorbent floor and wall finishes within at least 2 ft arcuna,,and perpendicular to such I openings plus at least one of the following 1.An installed awning at least 4 ft in dept,,_ 2. The door is protected by a roof overhang at least 4 ft in depth ' 3. The door is recessed at!east 4 ft 4 Other methods which provide equivalent prctection. 5.407.2.2.2 Flashing. install flashings integrated with a drainage ❑ ❑ plane. Construction Waste Reduction, Disposal and Recycling 5.408.1 Construction waste management. Recycle and/or salvage for reuse a minimum of 50 percent of the nonhazardous construction and demolition waste �n accordance with Section 5.408.1.1 5 408.1 2. or 5 408.1.3; or meet a ❑X ❑ local construction and demolition waste management ord nance. whichever is more stringent 5.408.1.1 Construction waste management plan. Submit plan per this ❑ section to enforcement authority 5.408.1.2 Waste management company. Utilize a waste management company that can provide verifiable documentation tha*the percentage of © ❑ construction and demolition waste material diverted from the fandfii complies with CalGreen Section 5.408 5.408.1.3 Waste stream reduction alternative. The combined weight of new construction, disposal that does not exceed two pounds per square ❑ foot of building area may be deemed to meet t-)e 50 percent minimum requirement as approved by the enforcing agency 5.408.1.4 Documentation. Provide documentation, of the waste © ❑ management plan that meets the requirements listed in Section 5.408 1 1 through 5.408.1 3. 5.408.3 Excavated soil and land clearing debris, 100 percent of trees, stumps, rocKs and associated vegetation and soils resulting pnmanly from land ❑ ❑ clearing shall be reused or recycled. Building Maintenance and Operation 5.410.1 Recycling by occupants. Provide readily accessible areas that serve the entire building and are identified for the depositing, storage and collection ❑ ❑ of nonhazardous materials for recycling 5.410.2 Commissioning. For new buildings 10,000 square feet and over. budding commissioning for all budding systems covered by T24. Part 6. process systems and renewable energy systems shat! be included in the ❑ ❑ design and construction processes of the building project Commissioning requirements shall include items listed in Section 5 410 2. Nage 4(if 9 CalGreen wi-Res Checklist dol rz,rived W 23 1 5.410.2.1 Owner's Project Requirements (OPR). Documented before the design phase of the project begins the OPR sha I inciude items I;sted in Section 5 410.4, 5.410.2.2 Basis of Design (BOD).A vrritten explanation of how the design of the building systems meets the OPR shall be completed at the design phase of the building project and updated periodically tc cover the systems listed in Secticn 5410.2.2 5.410.2.3 Commissioning plan.A commissioning plan describing how the j project will oe commissioned shall be started durirg the design phase of the building project and shall include items listed in Secticn 15 410.2 3 5.410.2.4 Functional performance testing. Purct onai perforr Bance testing shall demonstrate the correct installation and operation of each component, system and system-to-systenn interface in accordance with the approved plans and specifications. 5.410.2.5 Documentation and training. A Systems manual and systems operations training die iequired. 5.410.2.5.1 Systems manual. The systems mint al shall be delivered to the building owner or representative and facilities operator and shall include the items listed in Section 5.410.2.5.1. 5.410.2.5.2 Systems operations training. The training of the appropriate maintenance staff For each equipment type and/or system El shall include items listed in Section 5.410.25.2. 5.410.2.6 Commissioning report.A complete report of commissioning process activities undertaken through the design construction and ❑ ❑ reporting recommendations For post-construction phases of the building project shall be completed and provided to the owner or representative. 5.410.4 Testing and adjusting.Testing and adjusting of systems shall be required for buildings gess than 10,000 square feet or new systems to serve an addition or alteration subject to Section 303.1. r 5.410.4.2 Systems. Develop a written plan of procedures for testing and I adjusting systems Systems to be included for testing and adjusting shall include. as applicable to the project, the systems listed in Section 5.410.3.2 5.410.4.3 Procedures. Perform testing and adjusting procedures in accordance with industry best practices and applicable national standards In on each system 5.410.4.3.1 HVAC balancing. Before a new space-conditioning system serving a building or spaces operated for nor-nal use the system © ❑ should be balanced in accordance with the procedures defined by national standards listed in Section 5 410 3 3.1 5.410.4.4 Reporting.After completion of testing adjust ng and basancmg provide a final report of testing signed by the indiviouai responsible for performing these services. 5.410.4.5 Operation and maintenance manual. Provide the building owrer with detailed operating and maintenance instructions and copies of guaranties/warranties for each system prior to final insoection 5.410.4.5.1 Inspections and reports. Include a copy of all inspection ❑ verifications and reports required by the enforcing agency paec i M,9 CalGreen on-Ras Cherklisr_doc revised 0123 14 Fireplaces 5.503.1 Install only a direct-vent sealed-combustion gas or sealed wooc- burning fireplace or a sealed woodstove and refer to residential requirements ❑ ❑ m the California Energy Code. Title 24, Part 6. Subchapter 7. Section 150 5.503.1.1 Woodstoves. Woodstoves shall comply wit±i US EPA Phase II emission limits. ❑ ❑ Pollutant Control 5.504.3 Covering of duct openings and protection of mechanical equipment during construction. At the time of rUugh installation or during storage on the construction site and until final startup of the heating and cooling equipment. ail duct and other related air distribution component X❑ ❑ openings shall be covered with tape plastic sheet metal or othe,-methods acceptable to the enforcing agency to reduce the amount of dust or debris which may collect in the system 5.504.4 Finish material pollutant control. Finish materials shall comply with Sections 5.504.4.1 through 5.504.4.4. 5.504.4.1 Adhesives, sealants, caulks. Adhesives and sealants used on the project shall meet the requirements of the following standards 1. Adhesives, adhesive bonding primers, adhesive primers, sealants sealant primers and caulks shall comply with local or regional air pollution control or air quality management district rules where applicable or ❑ ❑ SCAGMD Rule 1 168 VOC limits, as shown in Tables 5 504.4.1 and 5.504 4,2 2 Aerosol adhesives and smaller unit sizes of adhesives and sealant or caulking compounds (in units of product. less packaging, which do not weigh more than one pound and do not consist of more than 16 fluid ounces) shall comply with statewide VOC standards and other 0 ❑ requirements, including prohibitions on use of cerlatn tox,c compounds, of California Code of Regulations, Title 17, commencing with Section 94507. 5.504.4.3 Paints and coatings. Architectural paints and coatings shall comply with Table 5.504.4.3 unless more stringent local limits apply. ® ❑ 5,504.4.3.1 Aerosol paints and coatings. Aerosol paints and coatings shall meet the Product-Weighted MIR Limits for ROC in Section 94522(ai(3)and other requirements, including prohibitions Uri use of ❑ certain toxic compounds and ozone depleting substances (CCR. Title /7, Section 94520 et seq) 5.504.4.3.2 Verification. Verification of compl;ante with this section shall be provided at the request of the enforcing agency ❑X ❑ 5.504.4.4 Carpet systems.All carpet installed in the building interior shall meet the testing and product requirements of at least one of the standards ❑ !fisted in Section 5. 504.4 4 ' 5.504.4.4.1 Carpet cushion. All carpet cushion installed in the building interior shall meet the requirements of the Carpet and Rug Institute ❑ ❑ Green Label program 5.504.4.4.2 Carpet adhesive.All ca+pet adsiesive snail meet the requirements of Table 5.504 4 1 ❑X ❑ I'ave 6 of9 CtIIGrean Nok?-Res revived RJ 23 14 5.504.4.5 Composite wood products. Hardwood plywood, particleboard and medium density fiberboard composite wood products used on the interior or exterior of the building shall meet the requirements for ® ❑ formaldehyde as specified in Table 5.504.4 5 5.504.4.5,3 Documentation. Verification of compliance with this section © ❑ shall be provides as requested by the enforcing agency Documentation shall incluse at least one of the follow:ng standards listed in Section 5 504.5 3 5.504.4.6 Resilient flooring systems. For 80 percent of floor area receiving resilient flooring, installed resilient floorng shall meet at least one ® ❑ of the following standards iisted in Section 5.504 4 6 I 5.504.5.3 Filters. In mechanically ventilated buildings, provide regularly occupied areas of the building w th air filtration media for outside and ® ❑ return air prior to occupancy that provides at least a N1ERV of 8 5.504.7 Environmental tobacco smoke (ETS) control, Prchibit smoking within 25 feet of building entries, outdoor air intakes ar.d operable windows where outdoor areas are provided for smoking and in buildings: or as enforced I ❑ ❑ by ordinances. regulations or policies of any city county, city and county California Community College, campus of the California '--late University or campus of the University of California, whichever are more stringent. Indoor Moisture and Radon Control 5.505.1 Indoor moisture control. Buildings shall meet or exceed the provisions of Califemia Budding Code. CCR. Title 24, Part 2, Sections 1203 ® ❑ and Chapter 14 1. Air Quality and Exhaust 5.506.1 Outside air delivery. For mechanically or naturally ventilated spaces in buildings meet the minimum requirements of Section 121 of the California ® ❑ Energy Code. CCR, Title 24. Part 6 and Chapter 4 of CCR. Title 8 or the applicable local code.whichever is more stringent.' 5.506.2 Carbon dioxide(CO2) monitoring. For buildings equipped with demand control ventilation, CO2 sensors and ventilation controls shall be specified and installed in accordance with the requirements of the latest edition of the California Energy Code. CCR, Title 24, Part 6, Section 121(c). ' Environmental Comfort 5.507.4 Acoustical control, Emoloy building assemblies and components with STC values determined in accordance with ASTM E 90 and ASTM E 413. ❑ ❑ 5.507.4.1 Exterior noise transmission. Wall and floor-ceiling assemblies making up the building envelope shall have an STC of at least 50 and exterior windows shall have a minimum STC of 30 for any of tree building ❑ locations listed in Items 1 through 3 in Section 5 507.5 1 5.507.4.2 Interior sound. Wall and floor-ceiling assemblies separating tenant spaces and tenant spaces and public places shall have an STC of ❑ ❑ at least 40 Page 7 of 9 CalGreen far-Res Checklisr.doc rewsed N 23 14 Outdoor Air Quality 5.508.1 Ozone depletion and greenhouse gas reductions.Installations of HVAC, refrigeration and fire suppression equipment shall comply with Sections 5.508.1.1 and 5.508.1.2. 5.608.1.1 Chlorofluorocarbons (CFCs)._Install HVAC and refrigeration equipment that does not contain CFCs. 5.508.1.2 Halons. Install fire suppression equipment that does not contain Halons. Lai i Page 8 of 9 CalGreen Non-Res Checklisr.doc revised 01.231 4 CALGREEN SIGNATURE DECLARATIONS Project Name: Fresh Pixx Pizza and Salad Project address: 20080 Stevens Creek, Ste. 106 Project Description: Design your own pizza and salad restaurant SECTION 1 — DESIGN VERIFICATION Complete all lines of Section 1 –"Design Verification"and submit the completed checklist(Columns 1 and 2) with the plans and building permit application to the Building Department. The owner and design professional responsible for compliance with CalGreen Standards have revised the plans and certify that the items checked above are hereby incorporated into the project plans and will be implemented into the project in accordance with the requirements set forth in the 2013 California Green Building Standards Code as adopte by the City ofC pertino / . R {�12 MCT Pfi7 T i�2 PwN 31 7� Y l t�- Owner's Signature Date 1,-2N i L-U-F FZ-- O 's Name (Pleas rin 03/10/2015 oaf on s Signa a Date Stephen 0. Jordan Design Profession2l's Name (Ple se Print) 02 2,11J Signature of Lice Profession responsible for CalGreen compliance Date 9i 6 -1117- -s"5rr Name of License Profes + al respon le for CalGreen compliance(Please Print) Phone 1^rG�C fir' -S 44 r QWeS ! , Nr:- Email Addre96 for License Professional responsible for CalGreen compliance SECTION 2 — IMPLEMENTATION VERIFICATION Complete, sign and submit the competed checklist, including column 3, together with all original signatures on Section 2 to the Building Department prior to Building Department final inspection. I have inspected the work and have received sufficient documentation to verify and certify that the project identified above was constructed in accordance with this Green Building Checklist and in accordance with the requirements of the 2013 C(alifotnia Gree Building Standards Code as adopted by the City of Cupertino. 3 a3 �s Signature of icen a of_es ioogl responsible for CalGreen compliance D e Name of License Professional responsible for CalGreen compliance(Please Print) Phone ri�� Ei'' SvrrewCs��+ et Email Addre s for License Professional responsible for CalGreen compliance Pale 9 ol'9 (alf`;reoi.AarRes( heckhcr.do( revised 0123 14 STATE OF CALIFORNIA OUTDOOR AIR ACCEPTANCE FILEY CEC-NRCA-MCH-02-A Revised 06/14 CALIFORNIA ENERGY COMMISSION CERTIFICATE OF ACCEPTANCE NRCA-MCH-02-A Outdoor Air Acceptance ag 3) Project Name: Enforcement Agency: Permit Number: Fresh Pixx Cupertino Building Dept. 1417111`117 Project Address: City: Zip Code: 20080 Stevens reek Blvd. Cu ertino CA. 95014 System Name or Identification/Tag: System location or Area Served: RTU-1Dining Note: Submit one Certificate of Acceptance for each system Enforcement Agency Use: Checked by/Date that must demonstrate compliance. Intent: Verify measured outside airflow reading is within f 10%of the total required outside airflow. Required for all newly installed HVAC units. Reference MECH-3C(Column H or Column I)or Mechanical Equipment Schedules. Construction Inspection Note: MCH-2A can be performed in conjunction with MCH-7A Supply Fan VFD Acceptance(if applicable)since testing activities overlap. 1. Supporting documentation needed to perform test includes: a. As-built and/or design documents(for example,Mechanical Equipment Schedules,Equipment Start-Up Sheets or Balancing Reports). b. 2013 Building Energy Efficiency Standards Nonresidential Compliance Manual(NA7.5.1.1 Ventilation Systems:Variable Air Systems At-A-Glance and NA7.5.1.2 Constant Volume Systems Outdoor AirAcceptance At-A-Glance). C. 2013 Building Energy Efficiency Standards. 2 Instrumentation needed to perform test includes: a. Watch b. Calibrated means to measure airflow(i.e.hot-wire anemometer,velocity pressure probe,etc.). i. Method and equipment used:Velgrid/Probe ii. Equipment calibration date(must be within one year): 12/30/14 3. System type(check either VAV or CAV): ❑ VAV X CAV a. Check if Variable Air Volume(VAV)and complete the following: L Outside airflow is either factory calibrated or field calibrated. i Check if factory calibrated and attach calibration certification. 7 Check if field calibrated and attach calibration results. ii. Damper Control(must be checked): t] Dynamic damper control is being used to control outside air. (This is NOT a fixed minimum position). iii. One of the following dynamic controls is being utilized to control outside air(check method used) Outdoor Air CFM Compensation i Energy Balance Method il Demand Control Ventilation ❑ Return Fan Tracking Injection Fan Method Dedicated Minimum Ventilation Damper with Pressure Control Other Active Control,Describe: b. Check if Constant Air Volume(CAV)and verify the following: X System is designed to provide a fixed minimum OSA when the unit is on. 4. Method of delivering outside air to the unit(check one of the following): I- Outside air is ducted to the return air plenum. Confirm that outside air is ducted to either(check one of the following): Within five ft.of the unit. Within 15 ft.of the unit,with the air directed substantially toward the unit. ,'!';'l Return air plenum is NOT used to distribute outside air to the unit. Le.outside air is ducted directly to the unit or outside air is provided independent of the unit. 5. Pre-occupancy purge has been programmed for the 1-hour period immediately before the building is normally occupied to provide(one of the following methods must be verified and checked): a. The conditioned floor area times the ventilation rate from the 2013 Building Energy Efficiency Standards TABLE 120.1-A,or 15 cfm per person times the expected number of occupants,whichever is less. b• 3 complete air changes to the zone served by the air handler. CA Building Energy Efficiency Standards-2013 Nonresidential Compliance June 2014 STATE OF CALIFORNIA OUTDOOR AIR ACCEPTANCE CEC-NRCA-MCH-02-A Revised 08/14 CALIFORNIA ENERGY COMMISSION CERTIFICATE OF ACCEPTANCE NRCA-MCH-02-A Outdoor Air Acceptance (Page 2 of 3) Project Name: Enforcement Agency: Permit Number: Fresh Pixx Cupertino Building t. 14120017 Project Address: City: Zip Code: 20080 Stevens r Blvd, Cu ertino CA. 95014 System Name or identification/Tag: System Location or Area Served: RTU-1 inin A. NA7.5.1.1 Outdoor Air Acceptance Functional Testing XCAV ❑VAV Step 1: Disable demand control ventilation(if applicable) Step 2- Verify unit is not in economizer mode during test(economizer disabled). X ❑ Note:Shaded boxes do not apply for CAV systems Step 3: CAV and VAV testing at full supply airflow a. Adjust supply air to achieve design airflow or maximum airflow at full cooling. Record VFD speed(Hz). Hz b. Measured outdoor airflow reading(cfm) 580 cfm cfm Required outdoor airflow(cfm)(from MECH-3C,Column 1,or C. Mechanical Equipment Schedules. ) 550 cfm cfm Time for outside air damper to stabilize after full supply airflow is achieved d' (minutes): min Step 4: VAV testing at reduced supply airflow CAV VAV a. Adjust supply airflow to either the sum of the minimum zone airflows,full heating,or 30%of the total design airflow. Record VFD speed(Hz). Hz b. Measured outdoor airflow reading(cfm) cfm C. Required outdoor airflow(cfm)(from MECH-3C,Column 1,or mechanical equipment schedules). cfm d. Time for outside air damper to stabilize after reduced supply airflow is achieved(minutes): min Step rr Return to initial conditions(check) X ❑ B. Testing Calculations&Results Determine Percent Outside Air at full supply airflow(%OAFA)for Step 2 a. %OAFA=Measured outdoor airflow reading/Required outdoor airflow(Step2b/Step2c) 105.5 % % b. %OAFA is within 10%of design Outside Air. (%OAFA 5110%) Q/ N Y / N C. Outside air damper position stabilizes within 5 minutes(Step 2d<5 minutes) Y / N Determine Percent Outside Air at reduced supply airflow(%OARA)for Step 3(VAV only) a. %OARA=Measured outdoor airflow reading/Required outdoor airflow reading(Step3b/Step3c) % b. %OARA is within 10%of design Outside Air. (OAS„5 110%) Y / N C. Outside air damper position stabilizes within S minutes(Step 3d<5 minutes) Y / N Note: The intent of this test is to ensure that 1)all air handlers provide the minimum amount of OSA and 2)VAV air handlers use dynamic controls to avoid over ventilation. C. Evaluation X PASS:All Construction Inspection responses are complete and Testing Calculations&Results responses are positive (Y-yes) CA Building Energy Efficiency Standards-2013 Nonresidential Compliance June 2014 STATE OF CALIFORNIA OUTDOOR AIR ACCEPTANCE CEC-NRCA-MCH-02 A Revised 06/14 CALIFORNIA ENERGY COMMISSION CERTIFICATE OF ACCEPTANCE NRCA-MCH-02-A Outdoor Air Acceptance (Page 3 of 3) Project Name: Enforcement Agency: Permit Number. Fresh Pixx Cupertino Building t. 14120017 Project Address: City: Zip Code: 20080 Stevens reek Blvd. u 95014 System Name or Identification/Tag: System Location or Area Served: RTU-1Dining DOCUMENTATION AUTHOR'S DECLARATION STATEMENT 1. I certify that this Certificate of Acceptance documentation is accurate and complete. Documentation Author Name:John Trusler Documentation Author Signature: Documentation Author Company Name: Date Signed: Sierra Mechanical Co oration 5/7/15 Address: ATT Certification Identification(If applicable): 3253 Fitz eral d. C"ity/State/Zp: Phone: Rancho Cordova CA. 95742 916-638-8605 FIELD TECHNICIAN'S DECLARATION STATEMENT I certify the following under penalty of perjury,under the laws of the State of California: 1. The information provided on this Certificate of Acceptance is true and correct. 2. 1 am the person who performed the acceptance verification reported on this Certificate of Acceptance(Field Technician). 3. The construction or installation identified on this Certificate of Acceptance complies with the applicable acceptance requirements indicated in the plans and specifications approved by the enforcement agency,and conforms to the applicable acceptance requirements and procedures specified in Reference Nonresidential Appendix NA7. 4. 1 have confirmed that the Certificate(s)of Installation for the construction or installation identified on this Certificate of Acceptance has been completed and signed by the responsible builder/installer and has been posted or made available with the building permit(s) issued for the building. Field Technician Name: Field Technician Signature: John Trusler Field Technician Company Name: Position with Company(Title): 00- Sierra Mechanical Co orationeneral Mann er Address: 3253 Fitzgerald Rd. ATT Certification Identification(if applicable): City/State/zip: Phone: Date Signed: Rancho Cordova, CA. 9574 916-638-8605 5/7/15 RESPONSIBLE PERSON'S DECLARATION STATEMENT I certify the following under penalty of perjury,under the laws of the State of California: 1. I am the Field Technician,or the Field Technician is acting on my behalf as my employee or my agent and I have reviewed the information provided on this Certificate of Acceptance. 2. 1 am eligible under Division 3 of the Business and Professions Code in the applicable classification to accept responsibility for the system design,construction or installation of features,materials,components,or manufactured devices for the scope of work identified on this Certificate of Acceptance and attest to the declarations in this statement(responsible acceptance person). 3. The information provided on this Certificate of Acceptance substantiates that the construction or installation identified on this Certificate of Acceptance complies with the acceptance requirements indicated in the plans and specifications approved by the enforcement agency,and conforms to the applicable acceptance requirements and procedures specified in Reference Nonresidential Appendix NA7. 4. 1 have confirmed that the Certificate(s)of Installation for the construction or installation identified on this Certificate of Acceptance has been completed and is posted or made available with the building permit(s)issued for the building. 5. 1 will ensure that a completed,signed copy of this Certificate of Acceptance shall be posted,or made available with the building permit(s)issued for the building,and made available to the enforcement agency for all applicable inspections. I understand that a signed copy of this Certificate of Acceptance is required to be included with the documentation the builder provides to the building owner at occupancy. Responsible Acceptance Person Name: Responsible Acceptance Person Signature: Jo Trusl r Responsible Acceptance Person Compan Name: Position with Company(Title): Sierra Mechanical Corporation Genera Mana er Address: CSLB license: 253 Fitzgerald Rd. 614027 City/State/Zip: Phone: Date Signed: Rancho Cordova CA. 95742 916-638-8605 5/7/15 CA Building Energy Efficiency Standards-2013 Nonresidential Compliance June 2014 STATE OF CALIFORNIA CONSTANT VOLUME SINGLE ZONE UNITARY (PACKAGED AND SPLIT) AIR CONDITIONER AND HEAT PUMP SYSTEMS CEC-NRCA-MCH-03-A Revised 06/14 CALIFORNIA ENERGY COMMISSION CERTIFICATE OF ACCEPTANCE NRCA-MCH-03-A Constant Volume Single Zone Unitary(Packaged and Split)Air Conditioner and Heat Pump Systems (Page 1 of 3) Project Name: Enforcement Agency: Permit Number: Fresh P' x Cu er ino Building Dept. 14120017 Project Address: City: Zip Code: 20080 Stevens Creek Blvd. Cupertino, CA. 95014 System Name or Identification/rag: System Location or Area Served: RIU-1 in' Note: Submit one Certificate of Acceptance for each system that must Enforcement Agency Use: Checked by/Date demonstrate compliance. Construction Inspection 1. Supporting documentation needed to perform test includes,but not limited to: a. 2013 Building Energy Efficiency Standards Nonresidential Compliance Manual(NA7.5.2 Constant Volume,Single-zone, UnitaryAir Conditioner and Heat Pumps Systems Acceptance At-A-Glance). b. 2013 Building Energy Efficiency Standards Manual. 2. Instrumentation to perform test includes,but not limited to: a. Temperature Meter b. Amp Meter 3. Installation(check if applies): X Thermostat is located within the space-conditioning zone that is served by the HVAC system. 4. Programming(check all those that apply): X Thermostat meets the temperature adjustment and dead band requirements of 2013 Building Energy Efficiency Standards Manual section 120.2(b). Minimum heating setpoint: 55 OF. Maximum cooling setpoint 85 OF. Deadband: 5 OF. X Occupied,unoccupied,and holiday schedules have been programmed per the facility's schedule. X Pre-occupancy purge has been programmed to meet the requirements of 2013 Building Energy Efficiency Standards Manual section 120.1(c)2. 1. Check method used to determine pre-occupancy purge: X Lesser of:conditioned floor area times ventilation rate from 2013 Building Energy Efficiency Standards TABLE 120.1-A or 15cfm per person times the expected number of occupants. Cl 3 complete air changes. Notes: CA Building Energy Efficiency Standards-2013 Nonresidential Compliance lune 2014 STATE OF CALIFORNIA CONSTANT VOLUME SINGLE ZONE UNITARY (PACKAGED AND SPLIT) AIR CONDITIONER AND HEAT PUMP SYSTEMS ` CEC-NRCA-MCH-03-A Revised 08/14 CALIFORNIA ENERGY COMMISSION CERTIFICATE OF ACCEPTANCE NRCA-MCH-03-A Constant Volume Single Zone Unitary(Packaged and Split)Air Conditioner and Heat Pump Systems (Page 2 of 3) Project Name: Enforcement Agency: Permit Number: Fresh Pixx Cupertino Building Dept. 14120017 Project Address: City: Zip Code: 20080 Stevens Creck Blvd. Cgperfino, CA. 95014 System Name or Identification/Tag: System Location or Area Served: RTU-1 Dininia A. Functional Testing Requirements Operating Modes Step 1: Disable economizer control and demand-controlled ventilation(if applicable)to prevent unexpected interactions. Occupied Mode Step 2: Heating load during occupied condition Step 3: No-load during occupied condition Step 4: Cooling load during occupied condition Unoccupied Mode Step 5: No-load during unoccupied condition Step 6: Heating load during unoccupied condition Step 7: Cooling load during unoccupied condition Step 8: Manual override 8 716 5 4 3 2 Step 2—8:Check and verify the following for each simulation mode required a. Supply fan operates continually X X X X b. Supply fan turns off X c. Supply fan cycles on and off X X d• System reverts to'occupied"mode to satisfy any condition X e. System turns off when manual override time period expires X f• Gas-fired furnace,heat pump,or electric heater stages onX X 9. No heating is provided by the unit XX X X h• No cooling is provided by the unit X X X X i• Compressor stages on X X J. Outside air damper is open to minimum position X X X X X k. Outside air damper closes completely RIX Step 9:System returned to initial operating conditions after all tests have been completed: a N B. Testing Results 1 8 1 71 6 1 .5 14 13 12 Indicate if Passed(P),Failed(F),or N/A(X),fill in appropriate letter P I P I P I P I P I P I P C. Evaluation: X I PASS:All Construction Inspection responses are complete and all applicable Testing Results responses are"Pass"(P) CA Building Energy Efficiency Standards-2013 Nonresidential Compliance June 2014 STATE OF CALIFORNIA CONSTANT VOLUME SINGLE ZONE UNITARY (PACKAGED AND SPLIT) AIR CONDITIONER AND HEAT PUMP SYSTEMS CEC-NRCA-MCH-03-A Revised 06114 CALIFORNIA ENERGY COMMISSION CERTIFICATE OF ACCEPTANCE NRCA-MCH-03-A Constant Volume Single Zone Unitary(Packaged and Split)Air Conditioner and Heat Pump Systems (Page 3 of 3) Project Name: Enforcement Agency: Permit Number. Fresh Pixx Cupertino Building Dept. 14120017 Project Address: City: Zip Code: 20080 StevensCreek Blvd. Cu ertino CA. 95014 System Name or Identification/Tag: System Location or Area Served: RTU-1 DOCUMENTATION AUTHOR'S DECLARATION STATEMENT 1. 1 certify that this Certificate of Acceptance documentation is accurate and complete. Documentation Author Name:John Trusler Documentation Author Signature: Documentation Author Company Name: Date Signed: Si rra Mechanical Corporation 5/7/15 Address: ATT Certification Identification(If applicable): 3253 Fitzgerald Rd. City/State/Zip: Phone: Rancho Cordova CA. 95742 916-638-8605 FIELD TECHNICIAN'S DECLARATION STATEMENT I certify the following under penalty of perjury,under the laws of the State of California: 1. The information provided on this Certificate of Acceptance is true and correct. 2. 1 am the person who performed the acceptance verification reported on this Certificate of Acceptance(Field Technician). 3. The construction or installation identified on this Certificate of Acceptance complies with the applicable acceptance requirements indicated in the plans and specifications approved by the enforcement agency,and conforms to the applicable acceptance requirements and procedures specified in Reference Nonresidential Appendix NA7. 4. 1 have confirmed that the Certificate(s)of Installation for the construction or installation identified on this Certificate of Acceptance has been completed and signed by the responsible builder/installer and has been posted or made available with the building permit(s) issued for the building. Field Technician Name: Field Technician Signature: John Trusler Field Technician Company Name: Position with company(Title): Sierra Mechanical Co oration eneral Manager Address:3253 Fitzgerald Rd. ATT Certification Identification(if applicable): City/State/Zip: Phone: Date Signed: Rancho Cordova CA. 95742 916-638-8605 5/7/15 RESPONSIBLE PERSON'S DECLARATION STATEMENT I certify the following under penalty of perjury,under the laws of the State of California: 1. 1 am the Field Technician,or the Field Technician is acting on my behalf as my employee or my agent and I have reviewed the information provided on this Certificate of Acceptance. 2. 1 am eligible under Division 3 of the Business and Professions Code in the applicable classification to accept responsibility for the system design,construction or installation of features,materials,components,or manufactured devices for the scope of work identified on this Certificate of Acceptance and attest to the declarations in this statement(responsible acceptance person). 3. The information provided on this Certificate of Acceptance substantiates that the construction or installation identified on this Certificate of Acceptance complies with the acceptance requirements indicated in the plans and specifications approved by the enforcement agency,and conforms to the applicable acceptance requirements and procedures specified in Reference Nonresidential Appendix NA7. 4. 1 have confirmed that the Certificate(s)of Installation for the construction or installation identified on this Certificate of Acceptance has been completed and is posted or made available with the building permit(s)issued for the building. 5. 1 will ensure that a completed,signed copy of this Certificate of Acceptance shall be posted,or made available with the building permit(s)issued for the building,and made available to the enforcement agency for all applicable inspections. I understand that a signed copy of this Certificate of Acceptance is required to be included with the documentation the builder provides to the building owner at occupancy. Responsible Acceptance Person Name: Responsible Acceptance Person Signature: John Trusler Responsible Acceptance Person Compan Name: Position with Company(Title): Sierra Mechanical Corporation Genera Mana er Address: CSLB License: 3253 Fitzgerald Rd. 614027 City/State/Zip: Phone: Date Signed: Rancho Cordova CA. 95742 916-638-8605 5/7/15 CA Building Energy Efficiency Standards-2013 Nonresidential Compliance June 2014 STATE OF CALIFORNIA AIR ECONOMIZER CONTROLS ACCEPTANCE 1 CEC-NRCA-MCH-05-A Revised 06/14 CALIFORNIA ENERGY COMMISSION CERTIFICATE OF ACCEPTANCE NRCA-MCH-05-A Air Economizer Controls Acceptance (Page 1 of 3) Project Name: Enforcement Agency: Permit Number: Fresh Pixx - Cupertino Building D t 14120 17 Project Address: city. Zip code: 20080 Stevens Creek Blvd. Cupertino, 95014 System Name or Identification/Tag: System Location or Area Served: RTU-1 Dining Note: Submit one Certificate of Acceptance for each system that must Enforcement Agency Use: Checked by/Date demonstrate compliance. A.Construction Inspection 1. Supporting documentation needed to perform test includes: a. 2013 Building Energy Efficiency Standards Nonresidential Compliance Manual(NA7.5.4 Air Economizer Controls Acceptance At-A- Glance). b. 2013 Building Energy Efficiency Standards. 2. Instrumentation to perform test includes: a. Hand-held temperature probe Calibration Date: 2/15 (must be within last year) b. Device capable of calculating enthalpy Calibration Date: 10/14 (must be within last year) c. 1.2 k Ohm Resistor(when specified by the manufacturer) 3. Installation:(all of the following boxes should be checked) X Economizer high limit shutoff control complies with Table 140.4-B found in the 2013 Building Energy Efficiency Standards Section 140.4(e)3. X Economizer reliability features are present per 2013 Building Energy Efficiency Standards Section 140.4(e)4: a.5-year manufacturer warranty of economizer assembly b.Provide a product specification sheet proving capability of at least 60,000 actuations c.Provide a product specification sheet proving compliance with AMCA Standard S00 damper leakage at 10 cfm/sf at 1.0 in w.g. A product specification sheet showing the manufacturer's results after following the testing procedures of AMCA Standard S00 or AMCA certification by a third party under AMCA Publication 511 can be used to satisfy this requirement(Class 1A,1,and 2 are acceptable). d.If the high limit setpoint is fixed dry-bulb or fixed enthalpy+fixed dry-bulb then the control shall have an adjustable setpoint e.Outdoor air,return air,mixed air,and supply air sensors shall be calibrated as follows: i.Drybulb and wetbulb temperatures accurate to t27 over the range of 40°F to 80oF ii.Enthalpy accurate to t3 Btu/Ib over the range of 20 Btu/Ib to 36 Btu/Ib iii.Relative humidity(RH)accurate to t5%over the range of 20%to 80%RH f.Check that the sensor performance curve(s)is provided by the factory and sensor output values measured during sensor calibration are plotted on the performance curve(s) g.Sensors used for high limit control shall be located to prevent false readings,including but not limited to being properly shielded from direct sunlight. • Unitary systems with an economizer have control systems,including two-stage or electronic thermostats,that cycle compressors off when economizers can provide partial cooling • System has return fan speed control,relief dampers,or dedicated relief fans to prevent building over pressurization in full economizer mode. X For systems with DDC controls,sensor used for economizer lockout has been factory or field calibrated. X For systems with non-DDC controls,manufacturer's startup and testing procedures have been applied. CA Building Energy Efficiency Standards-2013 Nonresidential Compliance June 2014 STATE OF CALIFORNIA AIR ECONOMIZER CONTROLS ACCEPTANCE WAR CEC-NRCA-MCH-OSA Revised 06/14 CALIFORNIA ENERGY COMMISSION CERTIFICATE OF ACCEPTANCE NRCA-MCH-05-A Air Economizer Controls Acceptance (Page 2 of 3) Project Name: Enforcement Agency: Permit Number: Fresh Pixx Coertino Building DOL 14120017 Project Address: City: Zip Code: 20080 Stevens Creek Blvd. Cu er ino CA. 95014 System Name or Identification/Tag: System Location or Area Served: RTU-1 Dining B. Functional Testing Results Step 1:Disable demand control ventilation systems(if applicable) Step 2:Enable the economizer and simulate a cooling demand large enough to drive the economizer fully open.Verify the following: a. Economizer damper modulates 100%open. (Z N b. Return air damper modulates 100%closed. d N C. For systems that meet the criteria of 2013 Building Energy Efficiency Standards Section 140.4(e)1,verify that the economizer remains 100%open with the use of mechanical cooling. This occurs when the cooling demand can no ( N longer be met by the economizer alone. d• All applicable fans and dampers operate as intended to maintain building pressure. IY N e• The unit heating is disabled(if applicable). ID N/NA Step 3:Disable the economizer and simulate a cooling demand.Verify the following: a. Economizer damper closes to its minimum position. LJ N b. All applicable fans and dampers operate as intended to maintain building pressure. LJ N C. The unit heating is disabled(if applicable). (2 N/NA Step 4:If the unit is equipped with heating,simulate a heating demand and enable the economizer.Verify the following: a. Economizer damper closes to its minimum position. N/NA b. Return air damper opens. ( N/NA Step 5:Turn off the unit and verify the following: a. Economizer damper closes completely. ON Step 6:System returned to initial operating conditions 0 N C. Testing Results PASS / FAIL Step 2:Simulate cooling load and enable the economizer(all answers are Y). Pass Step 3:Simulate cooling load and disable the economizer(all answers are Y). Pass Step 4:Simulate heating demand and enable the economizer(all answers are Y). Pass Step 5:Turn off the unit(all answers are Y). Pass D. Evaluation X PASS:All Construction Inspection responses are complete and all Testing Results responses are"Pass" Notes: CA Building Energy Efficiency Standards-2013 Nonresidential Compliance June 2014 STATE OF CALIFORNIA AIR ECONOMIZER CONTROLS ACCEPTANCE CEC-NRCA-MCH-05-A Revised 06/14 CALIFORNIA ENERGY COMMISSION CERTIFICATE OF ACCEPTANCE NRCA-MCH-05-A Air Economizer Controls Acceptance (Page 3 of 3) Project Name: Enforcement Agency: Permit Number: Fresh Pixx CuDerting Building Dot. 14120017 Project Address: City: Zip Code: 20080 Stevens Creels Blvd. CulDertino.CA. 95014 System Name or Identification/Tag: System Location or Area Served: RTU-1 Dining DOCUMENTATION AUTHOR'S DECLARATION STATEMENT 1. 1 certify that this Certificate of Acceptance documentation is accurate and complete. Documentation Author Name:John Trusler Documentation Author Signature: Documentation Author Company Name: Date Signed: Sierra Mechanical Corporation 5/7/15 Address: ATT Certification Identification(If applicabie): 3253 Fitz erald Rd. City/State/Zip: Phone: Rancho Cordova CA. 95742 916-638-8605 FIELD TECHNICIAN'S DECLARATION STATEMENT I certify the following under penalty of perjury,under the laws of the State of California: 1. The information provided on this Certificate of Acceptance is true and correct. 2. 1 am the person who performed the acceptance verification reported on this Certificate of Acceptance(Field Technician). 3. The construction or installation identified on this Certificate of Acceptance complies with the applicable acceptance requirements indicated in the plans and specifications approved by the enforcement agency,and conforms to the applicable acceptance requirements and procedures specified in Reference Nonresidential Appendix NA7. 4. 1 have confirmed that the Certificate(s)of Installation for the construction or installation identified on this Certificate of Acceptance has been completed and signed by the responsible builder/installer and has been posted or made available with the building permit(s) issued for the building. Field Technician Name:John Trusler Field Technician Signature: Field Technician Company Name: Position with Company(Title): Sierra Mechanical Co oration General Manner Address: 3253 Fitzgerald Rd. ATT Certification Identification(if applicable): City/State/Zip: Phone: Date Signed: Rancho Cordova CA. 95742 916-638-8605 5/7/15 RESPONSIBLE PERSON'S DECLARATION STATEMENT I certify the following under penalty of perjury,under the laws of the State of California: 1. 1 am the Field Technician,or the Field Technician is acting on my behalf as my employee or my agent and I have reviewed the information provided on this Certificate of Acceptance. 2. 1 am eligible under Division 3 of the Business and Professions Code in the applicable classification to accept responsibility for the system design,construction or installation of features,materials,components,or manufactured devices for the scope of work identified on this Certificate of Acceptance and attest to the declarations in this statement(responsible acceptance person). 3. The information provided on this Certificate of Acceptance substantiates that the construction or installation identified on this Certificate of Acceptance complies with the acceptance requirements indicated in the plans and specifications approved by the enforcement agency,and conforms to the applicable acceptance requirements and procedures specified in Reference Nonresidential Appendix NA7. 4. 1 have confirmed that the Certificate(s)of Installation for the construction or installation identified on this Certificate of Acceptance has been completed and is posted or made available with the building permit(s)issued for the building. 5. 1 will ensure that a completed,signed copy of this Certificate of Acceptance shall be posted,or made available with the building permit(s)issued for the building,and made available to the enforcement agency for all applicable inspections. I understand that a signed copy of this Certificate of Acceptance is required to be included with the documentation the builder provides to the building owner at occupancy. Responsible Acceptance Person Name: John Trusler Responsible Acceptance Person Signature: Responsible Acceptance Person CompaName: Position with Company(Title): Sierra Mechanical Co oration General Manner Address: CSLB License: 3253 Fitzgerald Rd. 614027 City/State/Zip: Phone: Date Signed: Rancho Cordova CA. 95742 916-638-8605 5/7/15 CA Building Energy Efficiency Standards-2013 Nonresidential Compliance lune 2014 STATE OF CALIFORNIA DEMAND CONTROL VENTILATION SYSTEMS ACCEPTANCE CEC-NBCA-MCH-06-A Revised 06/14 CALIFORNIA ENERGY COMMISSION CERTIFICATE OF ACCEPTANCE NRCA-MCH-06-A Demand Control Ventilation Systems Acceptance (Page 1 of 2) Project Name: Enforcement Agency: Permit Number: Fresh Pixx Cupertino Building Dot, Project Address: 14120017 city: Zip Code: 20080 Stevens CreekBlvd. C ertin CA. 95014 System Name or Identificationtrag: System Location or Area Served: RTU-1 Dining Note: Submit one Certificate of Acceptance for each system that Enforcement Agency Use: Checked by/Date must demonstrate compliance. Intent: �ased erify that systems required to employ demand Controlled ventilation(refer to§121(c)3)can vary outside ventilation flow rates on maintaining interior carbon dioxide(COJ concentration setpoints Construction Inspection 1 Instrumentation to perform test may include,but not limited to: a.Calibrated hand-held CO2 analyzer b.Manufacturer's calibration kit c.Calibrated CO2/air mixtures 2 Installation X The sensor is located in the high density space between 3ft and 6 ft above the floor or at the anticipated level of the occupants' heads. 3 Documentation of all carbon dioxide control sensors includes(check one of the following): a.Calibration method ❑ Factory-calibration(certificate calibration cert must be attached) X Field calibrated b.Sensor accuracy ❑ Certified by manufacturer to be no more than+/-75 ppm calibration cert must be attached A. Functional Testing Results a. Disable economizer controls b. Outside air CO'concentration(measured dynamically using CO2 sensor) T 523 ppm c. Interior CO2 concentration setpoint(Outside CO2 concentration+600 ppm) 1 123 ppm Step 1:Simulate a signal at or slightly above the CO2 setpoint or follow manufacturers recommended testing procedures. ❑ For single zone units,outdoor air damper modulates opens to satisfy the total ventilation air called for in the Certificate of Compliance. ❑ For multiple zone units,either outdoor air damper or zone damper modulate open to satisfy the zone ventilation requirements. Step 2:Simulate signal well below the CO2 setpoint or follow manufacturers recommended procedures. ❑ For single zone units,outdoor air damper modulates to the design minimum value. ❑ For multiple zone units,either outdoor air damper or zone damper modulate to satisfy the reduced zone ventilation requirements. Step 3:System returned to initial operating conditions Qy N Testing Results PASS / FAIL ❑ Step 1:Simulate a high CO'load(check box complete) N/A ❑ Step 2:Simulate a low CO2 load(check box complete) N/A C. Evaluation: ❑ PASS:All Construction Inspection responses are complete and all Testing Results responses are"Pass" N/A See *Note *Note: Step 1, 2,3 N/A per Exception to Section 120.1tc)4C CA Building Energy Efficiency Standards-2013 Nonresidential Compliance June 2014 STATE OF CALIFORNIA DEMAND CONTROL VENTILATION SYSTEMS ACCEPTANCE CEC-NRCA-MCH-06-A Revised 06/14 CALIFORNIA ENERGY COMMISSION CERTIFICATE OF ACCEPTANCE NRCA-MCH-06-A Demand Control Ventilation Systems Acceptance (Page 2 of 2) Project Name: Enforcement Agency: Permit Number: Fresh Pixx Building t 141 0017 Project Address: City: Zip Code: 20080 Stevens Creek Blvd. Cu ertino A. 95014 System Name or identffication/Tag: System Location or Area Served: RTU-1 Dining DOCUMENTATION AUTHOR'S DECLARATION STATEMENT 1. 1 certify that this Certificate of Acceptance documentation is accurate and complete. Documentation Author Name: John Trusler Documentation Author Signature: Documentation Author Company Name: Date Signed: Sierra Mechanical Corporation 5/7/15 Address:3253 Fitzgerald Rd. ATT Certification Identification(If applicable): City/State/Zip: Phone: Rancho Cordova CA. 95742 916-638-8605 FIELD TECHNICIAN'S DECLARATION STATEMENT I certify the following under penalty of perjury,under the laws of the State of California: 1. The information provided on this Certificate of Acceptance is true and correct. 2. 1 am the person who performed the acceptance verification reported on this Certificate of Acceptance(Field Technician). 3. The construction or installation identified on this Certificate of Acceptance complies with the applicable acceptance requirements indicated in the plans and specifications approved by the enforcement agency,and conforms to the applicable acceptance requirements and procedures specified in Reference Nonresidential Appendix NA7. 4. 1 have confirmed that the Certificate(s)of Installation for the construction or installation identified on this Certificate of Acceptance has been completed and signed by the responsible builder/installer and has been posted or made available with the building permit(s) issued for the building. Field Technician Name:John Tler Field Technician Signature: Field Technician Company Name: Position with Company(Title): Sierra Mechanical CqMoration General Manager Address: ATT Certification Identification(if applicable): 3253 Fitz erald Rd. Crty/State/Zip: Phone: Date Signed: Rancho Cordova CA. 95742 916-638-8605 5/7/15 RESPONSIBLE PERSON'S DECLARATION STATEMENT I certify the following under penalty of perjury,under the laws of the State of California: 1. I am the Field Technician,or the Field Technician is acting on my behalf as my employee or my agent and I have reviewed the information provided on this Certificate of Acceptance. 2. 1 am eligible under Division 3 of the Business and Professions Code in the applicable classification to accept responsibility for the system design,construction or installation of features,materials,components,or manufactured devices for the scope of work identified on this Certificate of Acceptance and attest to the declarations in this statement(responsible acceptance person). 3. The information provided on this Certificate of Acceptance substantiates that the construction or installation identified on this Certificate of Acceptance complies with the acceptance requirements indicated in the plans and specifications approved by the enforcement agency,and conforms to the applicable acceptance requirements and procedures specified in Reference Nonresidential Appendix NA7. 4. I have confirmed that the Certificate(s)of Installation for the construction or installation identified on this Certificate of Acceptance has been completed and is posted or made available with the building permit(s)issued for the building. 5. 1 will ensure that a completed,signed copy of this Certificate of Acceptance shall be posted,or made available with the building permit(s)issued for the building,and made available to the enforcement agency for all applicable inspections. I understand that a signed copy of this Certificate of Acceptance is required to be included with the documentation the builder provides to the building owner at occupancy. Responsible Acceptance Person Name: Responsible Acceptance Person Signature: John Truster Responsible Acceptance Person Company Name: Position with Company(Title): Sierra Mechanical Co oration General Manager Address: CSLB License: 3253 Fitzgerald Rd. 614027 City/State/Zip: Phone: Date Signed: Rancho Cordova CA. 95742 916-638-8605 5/7/15 CA Building Energy Efficiency Standards-2013 Nonresidential Compliance June 2014 STATE OF CALIFORNIA FAULT DETECTION AND DIAGNOSTICS FOR PACKAGED DIRECT EXPANSION UNITS CEC-NRCA-MCH-12-A Revised 06/14 CALIFORNIA ENERGY COMMISSION CERTIFICATE OF ACCEPTANCE NRCA-MCH-12-A Fault Detection and Diagnostics(FDD)for Packaged Direct Expansion Units (Page 1 of 3) Project Name: Enforcement Agency: Permit Number: Fresh Pixx Cupertino Building De t. 14120 17 Project Address: City: Zip Code: 20080 Stevens Creek Blvd. Cu ertino CA. -5014 [System Name or Identification/Tag: System location or Area Served: RTU-1 Dining Note: Submit one Certificate of Acceptance for each system that must Enforcement Agency Use: Checked by/Date demonstrate compliance. Construction Inspection 1 Prior to functional testing,verify and document the following: x The Fault Detection and Diagnostics(FDD)hardware is installed on the unit. The FDD system is certified to the California Energy Commission. The following air temperature sensors are permanently installed: X Outside Air Sensor X Supply Air Sensor X Return Air Sensor(applicable for differential economizer operation only) A Functional Testing Air Temperature Sensor Failure/Fault Step 1: Verify the FDD system indicates normal operation Step 2: Disconnect outside air temperature sensor from unit controller. Verify the following: X FDD system reports a fault Step 3: Connect outside air temperature sensor to unit controller. Verify the following: X FDD system indicates normal operation Excess Outside Air Step 1: Coordinate this test with NRCA-MCH-M2A(NA 7.5.1 Outdoor Air),if NRCA-MCH-02-A indicates"pass"then verify the following: X FDD system indicates normal operation Economizer Operation Step 1: Coordinate this test with NRCA-MCH-GSA(NA 7.5.4 Air Economizer Controls),and simulate failure by immobilizing the outdoor air economizer damper by disconnecting the control signal from the damper actuator(or another method specified by the manufacturer). Verify the following: X FDD system reports a fault Step 2: Successfully complete and pass NRCA-MCH-05-A and verify the following: X FDD system reports normal operation B Testing Results PASS / FAIL Test passes if all boxes are checked under Functional Testing. CA Building Energy Efficiency Standards-2013 Nonresidential Compliance June 2014 STATE OF CALIFORNIA FAULT DETECTION AND DIAGNOSTICS FOR PACKAGED DIRECT EXPANSION UNITS ., CEC-NRCA-MCH-12-A Revised 06/14 CALIFORNIA ENERGY COMMIS510N CERTIFICATE OF ACCEPTANCE NRCA-MCH-12-A Fault Detection and Diagnostics(FDD)for Packaged Direct Expansion Units (Page 2 of 3) Project Name: Enforcement Agency: Permit Number: Fresh Pixx Cu er ino Building Dept. 14120017 Project Address: City: Zip Code: 20080 Stevens Creek Blvd. Cupertino, CA. 95014 System Name or Identification/Tag: System Location or Area Served: RT -1 Dining C Evaluation: X PASS:All Construction Inspection responses are complete and Testing Results is"Pass" Notes: CA Building Energy Efficiency Standards-2013 Nonresidential Compliance June 2014 STATE OF CALIFORNIA FAULT DETECTION AND DIAGNOSTICS FOR PACKAGED DIRECT EXPANSION UNITS CEC-NRCA-MCH-12-A Revised 06114 CALIFORNIA ENERGY COMMISSION CERTIFICATE OF ACCEPTANCE NRCA-MCH-12-A Fault Detection and Diagnostics(FDD)for Packaged Direct Expansion Units (Page 3 of 3) Project Name: Enforcement Agency: Permit Nu mbar: Fresh Pixx Cupertino Blailding Dept. 14120017 Project Address: City: Zip Code: 20080 Stevens Creek Blvd. Cupeitim CA. 95014 System Name or Identification/Tag: System location or Area Served: RTU-1 Dining DOCUMENTATION AUTHOR'S DECLARATION STATEMENT 1. 1 certify that this Certificate of Acceptance documentation is accurate and complete. Documentation Author Name: Documentation Author Signature: John Trusler Documentation Author Company Name: Date Signed: Sierra Mechanical Co oration 5/7/15 Address: 3253 Fitzgerald Rd. ATT Certification Identification(If applicable): City/State/Zp: Rancho Cordova Phone:CA. 95742 916-638-8605 FIELD TECHNICIAN'S DECLARATION STATEMENT 1 certify the following under penalty of perjury,under the laws of the State of California: 1. The information provided on this Certificate of Acceptance is true and correct. 2. 1 am the person who performed the acceptance verification reported on this Certificate of Acceptance(Field Technician). 3. The construction or installation identified on this Certificate of Acceptance complies with the applicable acceptance requirements indicated in the plans and specifications approved by the enforcement agency,and conforms to the applicable acceptance requirements and procedures specified in Reference Nonresidential Appendix NA7. 4. 1 have confirmed that the Certificate(s)of Installation for the construction or installation identified on this Certificate of Acceptance has been completed and signed by the responsible builder/installer and has been posted or made available with the building permit(s) issued for the building. Field Technician Name:John Trusler Field Technician Signature: Field Technician Company Name: Position with Company(Title): Sierra Mechanical Co oration General Manager Address:3253 Fitzgerald Rd. ATT Certification Identification(if applicable): City/State/Zip: Phone: Date Signed: Rancho Cordova CA. 95742 916-638-8605 5/7/15 RESPONSIBLE PERSON'S DECLARATION STATEMENT I certify the following under penalty of perjury,under the laws of the State of California: 1. 1 am the Field Technician,or the Field Technician Is acting on my behalf as my employee or my agent and I have reviewed the information provided on this Certificate of Acceptance. 2. 1 am eligible under Division 3 of the Business and Professions Code in the applicable classification to accept responsibility for the system design,construction or installation of features,materials,components,or manufactured devices for the scope of work identified on this Certificate of Acceptance and attest to the declarations in this statement(responsible acceptance person). 3. The information provided on this Certificate of Acceptance substantiates that the construction or installation identified on this Certificate of Acceptance complies with the acceptance requirements indicated in the plans and specifications approved by the enforcement agency,and conforms to the applicable acceptance requirements and procedures specified in Reference Nonresidential Appendix NA7. 4. 1 have confirmed that the Certificate(s)of Installation for the construction or installation identified on this Certificate of Acceptance has been completed and is posted or made available with the building permit(s)issued for the building. 5. 1 will ensure that a completed,signed copy of this Certificate of Acceptance shall be posted,or made available with the building permit(s)issued for the building,and made available to the enforcement agency for all applicable inspections. I understand that a signed copy of this Certificate of Acceptance is required to be included with the documentation the builder provides to the building owner at occupancy. Responsible Acceptance Person Name: Responsible Acceptance Person Signature: John Trusler Responsible Acceptance Person Company Name: Position with Company(Title): Sierra Mechanical Co oration General Manager Address: CSLB License: 3253 Fitzgerald Rd. 614027 City/State/Zip: Phone: Date Signed: Rancho Cordova CA. 95742 916-638-8605 5/7/15 CA Building Energy Efficiency Standards-2013 Nonresidential Compliance June 2014 STATE OF CALIFORNIA OUTDOOR AIR ACCEPTANCE CEC-NRCA-MCH-02-A Revised 06/14 CALIFORNIA ENERGY COMMISSION - CERTIFICATE OF ACCEPTANCE NRCA-MCH-02 A Outdoor Air Acceptance (Page 1 of 3) Project Name: Enforcement Agency: Permit Number: Fresh Pixx Cupertino BuildingDept. 141 0017 Project Address: City: Zip Code: 20080 Stevens Creek Blvd. Cu ertino CA. 95014 System Name or Identification/Tag: System Location or Area Served: RTU-2 Kitchen Note: Submit one Certificate of Acceptance for each system Enforcement Agency Use: Checked by/Date that must demonstrate compliance. Verify measured outside airflow reading is within+10%of the total required outside airflow. Required for all newly installed HVAC Intent: units. Reference MECH-3C(Column H or Column 1)or Mechanical Equipment Schedules. Construction Inspection Note: MCH-2A can be performed in conjunction with MCH-7A Supply Fan VFD Acceptance(if applicable)since testing activities overlap. 1. Supporting documentation needed to perform test includes: a. As-built and/or design documents(for example,Mechanical Equipment Schedules,Equipment Start-Up Sheets or Balancing Reports). b. 2013 Building Energy Efficiency Standards Nonresidential Compliance Manual(NA7.5.1.1 Ventilation Systems:Variable Air Systems At-A-Glance and NA7.5.1.2 Constant Volume Systems Outdoor Air Acceptance At-A-Glance). c. 2013 Building Energy Efficiency Standards. 2 Instrumentation needed to perform test includes: a. Watch b. Calibrated means to measure airflow(i.e.hot-wire anemometer,velocity pressure probe,etc.). i. Method and equipment used:Velg'ld/Probe ii. Equipment calibration date(must be within one year): 12/30/14 3. System type(check either VAV or CAV): ❑ VAV X CAV a. Check if Variable Air Volume(VAV)and complete the following: L Outside airflow is either factory calibrated or field calibrated. Check if factory calibrated and attach calibration certification. Check if field calibrated and attach calibration results. ii. Damper Control(must be checked): L-1 Dynamic damper control is being used to control outside air. (This is NOT a fixed minimum position). iii. One of the following dynamic controls is being utilized to control outside air(check method used) Outdoor Air CFM Compensation Cl Energy Balance Method D Demand Control Ventilation IL Return Fan Tracking Injection Fan Method Dedicated Minimum Ventilation Damper with Pressure Control 1 Other Active Control,Describe: b. Check if Constant Air Volume(CAV)and verify the following: X System is designed to provide a fixed minimum OSA when the unit is on. 4. Method of delivering outside air to the unit(check one of the following): Outside air is ducted to the return air plenum. Confirm that outside air is ducted to either(check one of the following): Within five ft.of the unit. I Within 1S ft.of the unit,with the air directed substantially toward the unit. X Return air plenum is NOT used to distribute outside air to the unit. Le.outside air is ducted directly to the unit or outside air is provided independent of the unit. 5. Pre-occupancy purge has been programmed for the 1-hour period immediately before the building is normally occupied to provide(one of the following methods must be verified and checked): a. The conditioned floor area times the ventilation rate from the 2013 Building Energy Efficiency Standards TABLE 120.1-A,or 1S cfm per person times the expected number of occupants,whichever is less. b• 3 complete air changes to the zone served by the air handler. CA Building Energy Efficiency Standards-2013 Nonresidential Compliance June 2014 STATE OF CALIFORNIA OUTDOOR AIR ACCEPTANCE CEC-NRCA-MCH-02-A Revised 06114 CALIFORNIA ENERGY COMMISSION ` r CERTIFICATE OF ACCEPTANCE NRCA-MCH-02-A Outdoor Air Acceptance (Page 2 of 3) Project Name: Enforcement Agency: Permit Number: Fresh Pixx Cupertino Builftg Dept. 14120017 Project Address: City: Zip Code: 20080 Stevens Creek lv . Cu ertino CA. 95014 System Name or Identification/Tag: System location or Area Served: RTU-2 Kitchen A. NA7.5.1.1 Outdoor Air Acceptance Functional Testing XCAV ❑VAV Step 1: Disable demand control ventilation(if applicable) Step 2 Verify unit is not in economizer mode during test(economizer disabled). py ❑ Note:Shaded boxes do not apply for CAV systems Step 3: CAV and VAV testing at full supply airflow Adjust supply air to achieve design airflow or maximum airflow at full a. cooling. Record VFD speed(Hz). Hz b. Measured outdoor airflow reading(cfm) 568 cfm cfm Required outdoor airflow(cfm)(from MECH-3C,Column I,or C. Mechanical Equipment Schedules. j 550 cfm cfm d Time for outside air damper to stabilize after full supply airflow is achieved (minutes): min Step 4: VAV testing at reduced supply airflow CAV VAV a. Adjust supply airflow to either the sum of the minimum zone airflows,full heating,or 30%of the total design airflow. Record VFD speed(Hz). Hz b. Measured outdoor airflow reading(cfm) cfm C. Required outdoor airflow(cfm)(from MECH-3C,Column 1,or mechanical equipment schedules). cfm d. Time for outside air damper to stabilize after reduced supply airflow is achieved(minutes): min Step 5: Return to initial conditions(check) fly ❑ B. Testing Calculations&Results Determine Percent Outside Air at full supply airflow(%OAFA)for Step 2 a. %OAFA=Measured outdoor airflow reading/Required outdoor airflow(Step2b/Step2c) 103.3 % % b. %OAFA is within 10%of design Outside Air. (%OAFA 5110%) Q/ N Y / N C. Outside air damper position stabilizes within 5 minutes(Step 2d<5 minutes) Y / N Determine Percent Outside Air at reduced supply airflow(%OARA)for Step 3(VAV only) a. %OARA=Measured outdoor airflow reading/Required outdoor airflow reading(Step3b/Step3c) % b. %OArA is within 10%of design Outside Air. (OARA 5110%) Y / N C. Outside air damper position stabilizes within 5 minutes(Step 3d<5 minutes) Y / N Note: The intent of this test is to ensure that 1)all air handlers provide the minimum amount of OSA and 2)VAV air handlers use dynamic controls to avoid over ventilation. C. Evaluation: X PASS:All Construction Inspection responses are complete and Testing Calculations&Results responses are positive (Y-yes) CA Building Energy Efficiency Standards-2013 Nonresidential Compliance June 2014 STATE OF CALIFORNIA OUTDOOR AIR ACCEPTANCE CEC-NRCA-MCH-02-A Revised 06/14 CALIFORNIA ENERGY COMMISSION ' CERTIFICATE OF ACCEPTANCE NRCA-MCH-02-A Outdoor Air Acceptance (Page 3 o 3) Project Name: Enforcement Agency: Permit Number: Fresh Pixx Cupertino it D t. 14120017 Project Address: City: Zip Cade: 20080 Stevens Creek Blvd, i A 95014 PI-stem Name or Identification/Tag: System Location or Area Served: RTU-2 Kitchen DOCUMENTATION AUTHOR'S DECLARATION STATEMENT 1. I certify that this Certificate of Acceptance documentation is accurate and complete. Documentation Author Name: Documentation Author Signature: Jo Trusler Documentation Author Company Name: Date Signed: Sierra Mechanical Co oration 5/7/15 14p- 100, Address:32 Fitzgerald Rd. ATT Certification Identification(If applicable): City/StateRp: Phone: Rancho Cordova CA. 95742 916-638-8605 FIELD TECHNICIAN'S DECLARATION STATEMENT I certify the following under penalty of perjury,under the laws of the State of California: 1. The information provided on this Certificate of Acceptance is true and correct. 2. 1 am the person who performed the acceptance verification reported on this Certificate of Acceptance(Field Technician). 3. The construction or installation identified on this Certificate of Acceptance complies with the applicable acceptance requirements indicated in the plans and specifications approved by the enforcement agency,and conforms to the applicable acceptance requirements and procedures specified in Reference Nonresidential Appendix NAT 4. 1 have confirmed that the Certificate(s)of Installation for the construction or installation identified on this Certificate of Acceptance has been completed and signed by the responsible builder/installer and has been posted or made available with the building permit(s) issued for the building. Field Technician Name: Field Technician Signature: John Trusler Field Technician Company Name; Terra Mec Position with Company(Title): eneral Mana er Address: 3253 Fitzgerald Rd. ATT Certification Identification(if applicable): City/State/Zip: Phone: Date Signed: Rancho Cordova, CA. 9 742 916-638-8605 5/7/15 RESPONSIBLE PERSON'S DECLARATION STATEMENT I certify the following under penalty of perjury,under the laws of the State of California: 1. 1 am the Field Technician,or the Field Technician is acting on my behalf as my employee or my agent and I have reviewed the information provided on this Certificate of Acceptance. 2. 1 am eligible under Division 3 of the Business and Professions Code in the applicable classification to accept responsibility for the system design,construction or installation of features,materials,components,or manufactured devices for the scope of work identified on this Certificate of Acceptance and attest to the declarations in this statement(responsible acceptance person). 3. The information provided on this Certificate of Acceptance substantiates that the construction or installation identified on this Certificate of Acceptance complies with the acceptance requirements indicated in the plans and specifications approved by the enforcement agency,and conforms to the applicable acceptance requirements and procedures specified in Reference Nonresidential Appendix NA7. 4. 1 have confirmed that the Certificate(s)of Installation for the construction or installation identified on this Certificate of Acceptance has been completed and is posted or made available with the building permit(s)issued for the building. 5. 1 will ensure that a completed,signed copy of this Certificate of Acceptance shall be posted,or made available with the building permit(s)issued for the building,and made available to the enforcement agency for all applicable inspections. I understand that a signed copy of this Certificate of Acceptance is required to be included with the documentation the builder provides to the building owner at occupancy. Responsible Acceptance Person Name: Responsible Acceptance Person Signature: Jo T lr Responsible Acceptance Person CompanName: Position with Company(Title): §ierra Mechanical Co oration Genera Mana r Address: CSLB License: 3253 Fitzgerald Rd. 614027 City/State/Zip: Phone: Date Signed: Rancho Cordova CA. 95742 916-638-8605 5/7/15 CA Building Energy Efficiency Standards-2013 Nonresidential Compliance June 2014 STATE OF CALIFORNIA CONSTANT VOLUME SINGLE ZONE UNITARY(PACKAGED AND SPLIT) AIR CONDITIONER AND HEAT PUMP SYSTEMS CEC-NRCA-MCH-03-A Revised 06/14 CALIFORNIA ENERGY COMMISSION CERTIFICATE OF ACCEPTANCE NRCA-MCH-03-A Constant Volume Single Zone Unitary(Packaged and Split)Air Conditioner and Heat Pump Systems (Page 1 of 3) Project Name: Enforcement Agency: Permit Number: Fresh Pixx Cupertino Building De t. 14120017 Project Address: City: Zip Code: 20080 Stevens Creek Blvd. Cu ertino CA. 95014 System Name or Identification/rag: System Location or Area Served: RTU-2 Kitchen Note: Submit one Certificate of Acceptance for each system that must Enforcement Agency Use: Checked by/Date demonstrate compliance. Construction Inspection 1. Supporting documentation needed to perform test includes,but not limited to: a. 2013 Building Energy Efficiency Standards Nonresidential Compliance Manual(NA7.5.2 Constant Volume,Single-zone, Unitary Air Conditioner and Heat Pumps Systems Acceptance At-A-Glance). b. 2013 Building Energy Efficiency Standards Manual. 2. Instrumentation to perform test includes,but not limited to: a. Temperature Meter b. Amp Meter 3. Installation(check if applies): X Thermostat is located within the space-conditioning zone that is served by the HVAC system. 4. Programming(check all those that apply): X Thermostat meets the temperature adjustment and dead band requirements of 2013 Building Energy Efficiency Standards Manual section 120.2(b). Minimum heating setpoint: 55 oF. Maximum cooling setpoint 85 oF. Deadband: 5 oF. X Occupied,unoccupied,and holiday schedules have been programmed per the facility's schedule. X Pre-occupancy purge has been programmed to meet the requirements of 2013 Building Energy Efficiency Standards Manual section 120.1(c)2. 1. Check method used to determine pre-occupancy purge: X Lesser of:conditioned floor area times ventilation rate from 2013 Building Energy Efficiency Standards TABLE 120.1-A or 15cfm per person times the expected number of occupants. Ci 3 complete air changes. Notes: CA Building Energy Efficiency Standards-2013 Nonresidential Compliance June 2014 STATE OF CALIFORNIA CONSTANT VOLUME SINGLE ZONE UNITARY (PACKAGED AND SPLIT) AIR CONDITIONER AND HEAT PUMP SYSTEMS CEC-NRCA-MCH-03-A Revised 06/14 CALIFORNIA ENERGY COMMISSION " CERTIFICA•fE OF ACCEPTANCE NRCA-MCH-03-A Constant Volume Single Zone Unitary(Packaged and Split)Air Conditioner and Heat Pump Systems (Page 2 of 3) Project Name: Enforcement Agency: Permit Number: Fresh Pixx Cu ertino Building Dept. 14120017 Project Address: City: Zip Code: 20080 Stevens Creek Blvd. Cu ertino CA. 95014 System Name or Identification/Tag: System Location or Area Served: RTU-2 Kitchen A. Functional Testing Requirements Operating Modes Step 1: Disable economizer control and demand-controlled ventilation(if applicable)to prevent unexpected interactions. Occupied Mode Step 2: Heating load during occupied condition Step 3: No-load during occupied condition Step 4: Cooling load during occupied condition Unoccupied Mode Step 5: No-load during unoccupied condition Step 6: Heating load during unoccupied condition Step 7: Cooling load during unoccupied condition Step 8: Manual override 8 7 6 5 4 3 2 Step 2—8:Check and verify the following for each simulation mode required a• Supply fan operates continually X X X X b. Supply fan turns off X C. Supply fan cycles on and off X X d• System reverts to"occupied"mode to satisfy any condition X e. System turns off when manual override time period expires X f• Gas-fired furnace,heat pump,or electric heater stages on X X g• No heating is provided by the unit X X X X h• No cooling is provided by the unit X X X X I. Compressor stages on X X 1• Outside air damper is open to minimum position X X X X X k. Outside air damper closes completely X X Step 9:System returned to initial operating conditions after all tests have been completed: N B. Testing Results 8 1 7 16 5 14 3 2 Indicate if Passed(P),Failed(F),or N/A(X),fill in appropriate letter P I P I P I P P P P C. Evaluation: X I PASS:All Construction Inspection responses are complete and all applicable Testing Results responses are"Pass"(P) CA Building Energy Efficiency Standards-2013 Nonresidential Compliance June 2014 STATE OF CALIFORNIA CONSTANT VOLUME SINGLE ZONE UNITARY (PACKAGED AND SPLIT) AIR CONDITIONER AND HEAT PUMP SYSTEMS CEC-NRCA-MCH-03-A Revised 06/14 CALIFORNIA ENERGY COMMISSION CERTIFICATE OF ACCEPTANCE NRCA-MCH-03-A Constant Volume Single Zone Unitary(Packaged and Split)Air Conditioner and Heat Pump Systems (Page 3 of 3) Project Name: Enforcement Agency: Permit Number: Fre h Pixx Cu ertino Building De t. 14120017 Project Address: City: Zip Code: 20080 Stevens Creek Blvd. Cu ertino CA. 95014 System Name or Identification/Tag: System location or Area Served: RTU-2 DOCUMENTATION AUTHOR'S DECLARATION STATEMENT 1. 1 certify that this Certificate of Acceptance documentation is accurate and complete, Documentation Author Name:John Trusler Documentation Author Signature: Documentation Author Company Name: Date Signed: Sierra Mechanical Corporation 5/7/15 Address: ATT Certification Identification(If applicable): 3253 Fitzgerald Rd. City/State/Zip: Phone: Rancho Cordova CA. 95742 916-638-8605 FIELD TECHNICIAN'S DECLARATION STATEMENT I certify the following under penalty of perjury,under the laws of the State of California: 1. The information provided on this Certificate of Acceptance is true and correct. 2. 1 am the person who performed the acceptance verification reported on this Certificate of Acceptance(Field Technician). 3. The construction or installation identified on this Certificate of Acceptance complies with the applicable acceptance requirements indicated in the plans and specifications approved by the enforcement agency,and conforms to the applicable acceptance requirements and procedures specified in Reference Nonresidential Appendix NA7. 4. 1 have confirmed that the Certificate(s)of Installation for the construction or installation identified on this Certificate of Acceptance has been completed and signed by the responsible builder/installer and has been posted or made available with the building permit(s) issued for the building. Field Technician Name: Field Technician Signature: John Trusler Field Technician Company Name: Position with Company(Title): 000, Sierra Mechanical Co orationeneral Manager Address:3253 Fitz erald Rd. ATT Certification Identification(if applicable): City/State/Zip: Phone: Date Signed: Rancho Cordova CA. 95742 916-638-8605 5/7/15 RESPONSIBLE PERSON'S DECLARATION STATEMENT I certify the following under penalty of perjury,under the laws of the State of California: 1. 1 am the Field Technician,or the Field Technician is acting on my behalf as my employee or my agent and I have reviewed the information provided on this Certificate of Acceptance. 2. 1 am eligible under Division 3 of the Business and Professions Code in the applicable classification to accept responsibility for the system design,construction or installation of features,materials,components,or manufactured devices for the scope of work identified on this Certificate of Acceptance and attest to the declarations in this statement(responsible acceptance person). 3. The information provided on this Certificate of Acceptance substantiates that the construction or installation identified on this Certificate of Acceptance complies with the acceptance requirements indicated in the plans and specifications approved by the enforcement agency,and conforms to the applicable acceptance requirements and procedures specified in Reference Nonresidential Appendix NA7. 4. 1 have confirmed that the Certificate(s)of Installation for the construction or installation identified on this Certificate of Acceptance has been completed and is posted or made available with the building permit(s)issued for the building. 5. 1 will ensure that a completed,signed copy of this Certificate of Acceptance shall be posted,or made available with the building permit(s)issued for the building,and made available to the enforcement agency for all applicable inspections. I understand that a signed copy of this Certificate of Acceptance is required to be included with the documentation the builder provides to the building owner at occupancy. Responsible Acceptance Person Name: Responsible Acceptance Person Signature: John Trusler Responsible Acceptance Person CompanName: Position with Company(Title): Sierra Mechanical Co oration Genera Mana er Address: CSLB License: 3253 Fitzgerald Rd. 614027 City/State/Zip: Phone: Date Signed: Rancho Cordova CA. 95742 916-638-8605 5/7/15 CA Building Energy Efficiency Standards-2013 Nonresidential Compliance June 2014 STATE OF CALIFORNIA AIR ECONOMIZER CONTROLS ACCEPTANCE . CEC-NRCA-MCH-05-A Revised 06/14 CALIFORNIA ENERGY COMMISSION CERTIFICATE OF ACCEPTANCE NRCA-MCH-05-A Air Economizer Controls Acceptance (Page 1 of 3) Project Name: Enforcement Agency: Permit Number: Fresh Pixx Cupertino BuildingDept. 14120017 Project Address: Ciry: Zip Code: 20080 Stevens Creek Blvd. Cowin% CA, 5014 System Name or identification/Tag: System Location or Area Served: RTU-2 Kitchen Note: Submit one Certificate Of Acceptance for each system that must Enforcement Agency Use: Checked by/Date demonstrate compliance. A.Construction Inspection 1. Supporting documentation needed to perform test includes: a. 2013 Building Energy Efficiency Standards Nonresidential Compliance Manual(NAZ5.4 Air Economizer Controls Acceptance At-A- Glance). b. 2013 Building Energy Efficiency Standards. 2. Instrumentation to perform test includes: a. Hand-held temperature probe Calibration Date: 2/15 (must be within last year) b. Device capable of calculating enthalpy Calibration Date: 10/14 (must be within last year) c. 1.2 k Ohm Resistor(when specified by the manufacturer) 3- Installation:(all of the following boxes should be checked) X Economizer high limit shutoff control complies with Table 140.4-B found in the 2013 Building Energy Efficiency Standards Section 140.4(e)3. X Economizer reliability features are present per 2013 Building Energy Efficiency Standards Section 140.4(e)4: a.5-year manufacturer warranty of economizer assembly b.Provide a product specification sheet proving capability of at least 60,000 actuations c.Provide a product specification sheet proving compliance with AMCA Standard 500 damper leakage at 10 cfm/sf at 1.0 in w.g. A product specification sheet showing the manufacturer's results after following the testing procedures of AMCA Standard 500 or AMCA certification by a third party under AMCA Publication 511 can be used to satisfy this requirement(Class 1A,1,and 2 are acceptable). d.If the high limit setpoint is fixed dry-bulb or fixed enthalpy+fixed dry-bulb then the control shall have an adjustable setpoint e.Outdoor air,return air,mixed air,and supply air sensors shall be calibrated as follows: L Drybulb and wetbulb temperatures accurate to t2"F over the range of 40°F to 80°F ii.Enthalpy accurate to t3 Btu/Ib over the range of 20 Btu/Ib to 36 Btu/Ib iii.Relative humidity(RH)accurate to t5%over the range of 20%to 80%RH f.Check that the sensor performance curve(s)is provided by the factory and sensor output values measured during sensor calibration are plotted on the performance curve(s) g.Sensors used for high limit control shall be located to prevent false readings,including but not limited to being properly shielded from direct sunlight. X Unitary systems with an economizer have control systems,including two-stage or electronic thermostats,that cycle compressors off when economizers can provide partial cooling X System has return fan speed control,relief dampers,or dedicated relief fans to prevent building over pressurization in full economizer mode. X For systems with DDC controls,sensor used for economizer lockout has been factory or field calibrated. X For systems with non-DDC controls,manufacturer's startup and testing procedures have been applied. CA Building Energy Efficiency Standards-2013 Nonresidential Compliance June 2014 STATE OF CALIFORNIA AIR ECONOMIZER CONTROLS ACCEPTANCE CEC-NRCA-MCH-05-A Revised 06/14 CALIFORNIA ENERGY COMMISSION ~ CERTIFICATE OF ACCEPTANCE NRCA-MCH-05-A Air Economizer Controls Acceptance (Page 2 of 3) Project Name: Enforcement Agency: Permit Number. Fresh Pixx Cupertino Buildingt 141 017 ProjectAddress: City: Zip Code: 0080 Stevens Creek Blvd. —Cuperting, CA. 95014 System Name or IdentiFlatlon/Tag: System Location or Area Served: RTU-2Kitchen B. Functional Testing Results Step 1:Disable demand control ventilation systems(if applicable) Step 2:Enable the economizer and simulate a cooling demand large enough to drive the economizer fully open.Verify the following: a. Economizer damper modulates 100%open. (Z N b. Return air damper modulates 100%closed. ON C. For systems that meet the criteria of 2013 Building Energy Efficiency Standards Section 140.4(e)1,verify that the economizer remains 100%open with the use of mechanical cooling. This occurs when the cooling demand can no OY N longer be met by the economizer alone. d• All applicable fans and dampers operate as intended to maintain building pressure. N e• The unit heating is disabled(if applicable). (Z N/NA Step 3:Disable the economizer and simulate a cooling demand.Verify the following: a. Economizer damper closes to its minimum position. N b. All applicable fans and dampers operate as intended to maintain building pressure. N C. The unit heating is disabled(if applicable). (2y N/NA Step 4:If the unit is equipped with heating,simulate a heating demand and enable the economizer.Verify the following: a. Economizer damper closes to its minimum position. N/NA b. Return air damper opens. N/NA Step 5:Turn off the unit and verify the following: a. Economizer damper closes completely. (ZY N Step 6:System returned to initial operating conditions -ON C. Testing Results PASS / FAIL Step 2:Simulate cooling load and enable the economizer(all answers are Y). Pass Step 3:Simulate cooling load and disable the economizer(all answers are Y). Pass Step 4:Simulate heating demand and enable the economizer(all answers are Y). P ass Step 5:Turn off the unit(all answers are Y). Pass D. Evaluation X PASS:All Construction Inspection responses are complete and all Testing Results responses are"Pass" Notes: CA Building Energy Efficiency Standards-2013 Nonresidential Compliance June 2014 STATE OF CALIFORNIA AIR ECONOMIZER CONTROLS ACCEPTANCE CEC-NRCA-MCH-05-A Revised 06/14 CALIFORNIA ENERGY COMMISSION CERTIFICATE OF ACCEPTANCE NRCA-MCH-05-A Air Economizer Controls Acceptance (Page 3 of 3) Project Name: Enforcement Agency: Permit Number: Fresh Pixx Cupertino Building t. 14120017 Project Address: City: Zip Code: 20080 Stevens Creek Blvd. Cu ertino CA. 95014 System Name or identification/Tag: System Location or Area Served: TU-2 Kitchen DOCUMENTATION AUTHOR'S DECLARATION STATEMENT 1. 1 certify that this Certificate of Acceptance documentation is accurate and complete. Documentation Author Name: T Documentation Author Signature: John lr Documentation Author Company Name: Date Signed: Sierra Mechanical Corporation 5/7/15 Address: ATT Certification Identification(If applicable): 3253 Fitzgerald Rd. City/State/Zip: Phone: Rancho Cordova, CA. 95742 916-638-8605 FIELD TECHNICIAN'S DECLARATION STATEMENT I certify the following under penalty of perjury,under the laws of the State of California: 1. The information provided on this Certificate of Acceptance is true and correct. 2. 1 am the person who performed the acceptance verification reported on this Certificate of Acceptance(Field Technician). 3. The construction or installation identified on this Certificate of Acceptance complies with the applicable acceptance requirements indicated in the plans and specifications approved by the enforcement agency,and conforms to the applicable acceptance requirements and procedures specified in Reference Nonresidential Appendix NAT 4. 1 have confirmed that the Certificate(s)of Installation for the construction or installation identified on this Certificate of Acceptance has been completed and signed by the responsible builder/installer and has been posted or made available with the building permit(s) issued for the building. Field Technician Name:John Trusler Field Technician Signature: Field Technician Company Name: Position with Company(Title): Sierra Mechanical Corporation General Manner Address: 3253 Fitzgerald Rd. ATT Certification Identification(if applicable): City/State/Zip: Phone: Date Signed: Rancho Cordova CA. 95742 916-638-8605 5/7/15 RESPONSIBLE PERSON'S DECLARATION STATEMENT I certify the following under penalty of perjury,under the laws of the State of California: 1. 1 am the Field Technician,or the Field Technician is acting on my behalf as my employee or my agent and I have reviewed the information provided on this Certificate of Acceptance. 2. 1 am eligible under Division 3 of the Business and Professions Code in the applicable classification to accept responsibility for the system design,construction or installation of features,materials,components,or manufactured devices for the scope of work identified on this Certificate of Acceptance and attest to the declarations in this statement(responsible acceptance person). 3. The information provided on this Certificate of Acceptance substantiates that the construction or installation identified on this Certificate of Acceptance complies with the acceptance requirements indicated in the plans and specifications approved by the enforcement agency,and conforms to the applicable acceptance requirements and procedures specified in Reference Nonresidential Appendix NAT 4. I have confirmed that the Certificate(s)of Installation for the construction or installation identified on this Certificate of Acceptance has been completed and is posted or made available with the building permit(s)issued for the building. 5. 1 will ensure that a completed,signed copy of this Certificate of Acceptance shall be posted,or made available with the building permit(s)issued for the building,and made available to the enforcement agency for all applicable inspections. I understand that a signed copy of this Certificate of Acceptance is required to be included with the documentation the builder provides to the building owner at occupancy. Responsible Acceptance Person Name: John Trusler Responsible Acceptance Person Signature: Responsible Acceptance Person CompaName: Position with Company(Title): Siena Mechanical Co oration General Manager Address: CSLB license: 3253 Fitzgerald Rd. 614027 City/State/Zip: Phone: Date Signed: Rancho Cordova CA. 95742 916-638-8605 5/7/15 CA Building Energy Efficiency Standards-2013 Nonresidential Compliance June 2014 STATE OF CALIFORNIA FAULT DETECTION AND DIAGNOSTICS FOR PACKAGED DIRECT EXPANSION UNITS ,, CEC-NRCA-MCH-12-A Revised 06/14 CALIFORNIA ENERGY COMMISSION CERTIFICATE OF ACCEPTANCE NRCA-MCH-12-A Fault Detection and Diagnostics(FDD)for Packaged Direct Expansion Units (Page 1 of 3) Project Name: Enforcement Agency: Permit Number: Fresh Pixx Cu ertino Building Dept. 14120017 Project Address: City: Zip Code: 20080 Stevens Creek Blvd. Cu ertino CA. 95014 System Name or Identificationfrag: Served:System Location or Area Sed: RTU-2 Kitchen Note: Submit one Certificate of Acceptance for each system that must Enforcement Agency Use: Checked by/Date demonstrate compliance. Construction Inspection 1 Priorto functional testing,verify and documentthe following: • The Fault Detection and Diagnostics(FDD)hardware is installed on the unit. • The FDD system is certified to the California Energy Commission. The following air temperature sensors are permanently installed: A Outside Air Sensor • Supply Air Sensor X Return Air Sensor(applicable for differential economizer operation only) A Functional Testing Air Temperature Sensor Failure/Fault Step 1: Verify the FDD system indicates normal operation Step 2: Disconnect outside air temperature sensor from unit controller. Verify the following: X FDD system reports a fault Step 3: Connect outside air temperature sensor to unit controller. Verify the following: X FDD system indicates normal operation Excess Outside Air Step 1: Coordinate this test with NRCA-MCH-tVA(NA 7.5.1 Outdoor Air),if NRCA-MCH-02-A indicates"pass"then verify the following: X FDD system indicates normal operation Economizer Operation Step 1: Coordinate this test with NRCA-MCH-05A(NA 7.5.4 Air Economizer Controls),and simulate failure by immobilizing the outdoor air economizer damper by disconnecting the control signal from the damper actuator(or another method specified by the manufacturer). Verify the following: X FDD system reports a fault Step 2: Successfully complete and pass NRCA-MCH-05-A and verify the following: X FDD system reports normal operation B Testing Results PASS / FAIL Test passes if all boxes are checked under Functional Testing. ❑ CA Building Energy Efficiency Standards-2013 Nonresidential Compliance June 2014 STATE OF CALIFORNIA FAULT DETECTION AND DIAGNOSTICS FOR PACKAGED DIRECT EXPANSION UNITS ., r,*: CEC-NRCA-MCH-12-A Revised 06/14 CALIFORNIA ENERGY COMMISSION CERTIFICATE OF ACCEPTANCE NRCA-MCH-12-A Fault Detection and Diagnostics(FDD)for Packaged Direct Expansion Units (Page 2 of 3) Project Name: Enforcement Agency: Permit Number: Fresh Pixx Cu ertino Building Dept. 14120017 Project Address: City: Zip Code: 2 080 Stevens Creek Blvd. Cu ertino CA. 95014 System Name or identification/rag: System Location or Area Served: U-2 Kitchen C Evaluation: X PASS:All Construction Inspection responses are complete and Testing Results is"Pass" Notes: CA Building Energy Efficiency Standards-2013 Nonresidential Compliance June 2014 STATE OF CALIFORNIA FAULT DETECTION AND DIAGNOSTICS FOR PACKAGED DIRECT EXPANSION UNITS _ .M CEC-NRCA-MCH-12-A Revised 06/14 CALIFORNIA ENERGY COMMISSION CERTIFICATE OF ACCEPTANCE NRCA-MCH-12-A Fault Detection and Diagnostics(FDD)for Packaged Direct Expansion Units (Page 3 of 3) Project Name: Enforcement Agency: Permit Number: Fresh Pixx Cupertino Building Dept. 14120017 Project Address: City; ZIP Code: 20080 Stevens Creek Blvd. Cupertino, CA. 95014 System Name or Identifiration/Tag: System Location or Area Served: RTU-2 Kitchen DOCUMENTATION AUTHOR'S DECLARATION STATEMENT 1. 1 certify that this Certificate of Acceptance documentation is accurate and complete. Documentation Author Name: Documentation Author Signature: ohn Trusler Documentation Author Company Name: Date Signed: Sierra Mechanical Co oration 5/7/15 Address: ATT Certification Identification(N applicable): 3253 Fitzgerald Rd. City/State/Zip: Phone: Rancho Cordova, CA. 95742 916-638-8605 FIELD TECHNICIAN'S DECLARATION STATEMENT I certify the following under penalty of perjury,under the laws of the State of California: 1. The information provided on this Certificate of Acceptance is true and correct. 2. 1 am the person who performed the acceptance verification reported on this Certificate of Acceptance(Field Technician). 3. The construction or installation identified on this Certificate of Acceptance complies with the applicable acceptance requirements indicated in the plans and specifications approved by the enforcement agency,and conforms to the applicable acceptance requirements and procedures specified in Reference Nonresidential Appendix NA7. 4. 1 have confirmed that the Certificate(s)of Installation for the construction or installation identified on this Certificate of Acceptance has been completed and signed by the responsible builder/installer and has been posted or made available with the building permit(s) issued for the building. Field Technician Name:John Trusler Field Technician Signature: Field Technician Company Name: Position with Company(Title): Sierra Mechanical Co oration General Manager Address:3253 Fitz erald Rd. ATT Certification identification(it applicable): City/State/Zip: Phone: Date Signed: Rancho Cordova CA. 95742 916-638-8605 5/7/15 RESPONSIBLE PERSON'S DECLARATION STATEMENT I certify the following under penalty of perjury,under the laws of the State of California: 1. 1 am the Field Technician,or the Field Technician is acting on my behalf as my employee or my agent and I have reviewed the information provided on this Certificate of Acceptance. 2. 1 am eligible under Division 3 of the Business and Professions Code in the applicable classification to accept responsibility for the system design,construction or installation of features,materials,components,or manufactured devices for the scope of work identified on this Certificate of Acceptance and attest to the declarations in this statement(responsible acceptance person). 3. The information provided on this Certificate of Acceptance substantiates that the construction or installation identified on this Certificate of Acceptance complies with the acceptance requirements indicated in the plans and specifications approved by the enforcement agency,and conforms to the applicable acceptance requirements and procedures specified in Reference Nonresidential Appendix NA7. 4. 1 have confirmed that the Certificate(s)of Installation for the construction or installation identified on this Certificate of Acceptance has been completed and is posted or made available with the building permit(s)issued for the building. 5. 1 will ensure that a completed,signed copy of this Certificate of Acceptance shall be posted,or made available with the building permit(s)issued for the building,and made available to the enforcement agency for all applicable inspections. I understand that a signed copy of this Certificate of Acceptance is required to be included with the documentation the builder provides to the building owner at occupancy. Responsible Acceptance Person Name:John Trusler Responsible Acceptance Person Signature: Responsible Acceptance Person Company Name: Position with Company(Title): Sierra Mechanical Co oration General Manager Address: CSLB License: 3253 Fitzgerald Rd. 614027 City/State/Zip: Phone: Date Signed: Rancho Cordova CA. 95742 916-638-8605 5/7/15 CA Building Energy Efficiency Standards-2013 Nonresidential Compliance June 2014