HomeMy WebLinkAboutB-2017-1932P,
LA
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2017-1932
2 RESULTS WAY CUPERTINO, CA 95014-5924 (357 20 042)
TCG BUILDERS INC
MILPITAS, CA 95035
OWNER'S NAME: BVK PERIMETER SQUARE RETAIL LLC ET AL
DATE ISSUED: 11/09/2017
OWNER'S PHONE: 650-421-1832
PHONE NO: (408) 321-6450
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class 5 Lic. #835597
Contractor TCG BUILDERS INC Date 04/30/2018
X BLDG —ELECT —PLUMB
MECH RESIDENTIAL X COMMERCIAL
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing
_
with Section 7000) of Division 3 of the Business & Professions Code and that my
license is in full force and effect.
JOB DESCRIPTION:
APPLE; 2ND FLOOR - T.I. (I 100 S.F.)
I hereby affirm under penalty of perjury one of the following two declarations:
t. 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
erformance of the work for which this permit is issued.
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
Sq. Ft Floor Area:
Valuation: $157866.00
permit is issued.
- APPLICANT CERTIFICATION
I certify that I have read this application and state that the above
APN Number:
Occupancy Type:
information is correct. I agree to comply with all city and county ordinances
357 20 042
B (Tenant Improvements)
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, costs, and expenses which
PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City iri consequence of the granting of this permit.
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally, the applicant understands and will comply with all non -point
source regulations per th u ino Municipal Code, Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
l -, gnature Date 1'1/9/2017
Issued by: Abby Avende
Date: 11/09/2017
OWNER -BUILDER DECLARATION
I hereby affirm that it am,ezetinpf from the Contractor's License.Law for one of the
RE -ROOFS:
following two, reasons:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
1. I, as owner of the property,,or my employees with wages as their sole
installed without first obtaining an inspection, I agree to remove all new materials for
compensation, will do the work, and the structure is not intended or offered for
inspection.
sale (Sec.7044, Business & Professions Code)
2. I, as owner of the property, am exclusively contracting with licensed
Signature of Applicant:
contractors to construct the project (Sec.7044, Business & Professions Code).
Date: 11/9/2017
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
t. 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.
HAZARDOUS MATERIALS DISCLOSURE
2. I have and will maintain Worker's Compensation Insurance, as provided for by
I have read the hazardous materials requirements under Chapter 6.95 of the
Section 3700 ofthe Labor Code, for the performance of the work for which this
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
permit is issued.
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
3. I certify•that in the performance of the work for which this permit is issued, I
Health & Safety Code, Section 25532(a) should I store or handle hazardous
shall not employ any person in any manner so as to become subject to the
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of Califomia. If, after making this certificate of
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
exemption, I become subject to the Worker's Compensation provisions of the
the Health & Safety Code, S O5, 25533, and 25534.
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed revoked.
+3n er or authorized agent:
APPLICANT CERTIFICATION
ate: 11/912017
1 certify that I have read this application and state that the above information is
CONSTRUCTION LENDING AGENCY
correct. I agree to comply with all city and county ordinances and state laws
I hereby affirm that there is a construction lending agency for the performance
relating to building construction, and hereby authorize representatives of this city
of work's for which this permit is issued (Sec. 3097, Civ C.)
to enter upon the above mentioned property for inspection purposes. (We) agree
Lender's Name
to save indemnify, and keep harmless the City of Cupertino against liabilities,
judgments, costs, and expenses which may accrue against said City in
Lender's Address
consequence of the granting of this permit. Additionally, the applicant understands
and will comply with all non -point source regulations per the Cupertino Municipal
ARCHITECT'S DECLARATION
Code, Section 9.18.
1 understand my plans shall be used as public records.
Licensed
Signature Date 11/9/2017
Professional
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255[a
(408) 777-3228 • building@cupertino.orPEMIT #B
CUPERTINO REV# DEF#
❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION XT.l. ❑ MEP ❑ RE -ROOF ❑ SWIMMING POOL/SPA
PROJECT DRESS Aia'atts, ^ Qr APN t 3S+ ` 20
o 00 t
OW NAMer ch� (► h A A PHONE • +� • �� E-MAIL �l
✓QVC
SrI i Nte a� JACD,_ CITY, ST TE, ZIPevglirlo `//1/�]. I - ai�' 4—
CONTRACTOR NAME ❑ OW ER -BUILDER COMPANY NAME LICENSE NUMBER LICENSE TYPE
1r,6 I?ku)ders
STREET 10 rl M C(dilty •5-tj . 100
CITY, ST4TB,1 CA- 4 / - _/�
E-MAIL PHONE N)1BUS. LIC #
At li nlo�fi r�.i1 �erS • nn ATZ . 08'2.49 2,�g 5l0
ARCHITECT ❑OWNER NERAGENT WCONTRACTOR AGENT ❑ ENGINEER ❑DEVELOPER❑TENNANT
CONTA E-MAIL
Wwl Aek\ NMJ
jyv
TREET
SST I p DRQ CITYI v I lF�bZIP, tW=//.PHO 1 t'&
I9)x4041iC6)0I
TT �. �r ; ti � ► o� �� �' o�'c� -tom i �4
❑SINGLE-FAMILY/DUPLEX, ❑ MULTI -FAMILY ❑ INDUSTRIAL COMMERCIAL
EXISTING USE EXISTING SF� NEW FLOOR SF PORCH SF I DECK SF DEMO SF STORIES # TOTAL NET SF USE TYPE OCC SQ.FT: , VALUATION ($)
REMODEL REMODEL KITCHEN REMODEL OTHR GARAGE ❑ ATTACHED
BATHROOM SF 'SF i SF SF❑DETACHED
EXISINGOYES E16HLER ❑ YES SECOND STORY ADDITION ❑YES
FIRE SPRINKLERS ❑ NO. ❑ NO ❑ NO
DWELLING I SECOND DWELLING ❑ YEs ❑ ATTACHED❑ DETACHED I OTHER
UNITS # UNITADDITON: ❑ NO S F
a'
POOLS ❑ FIBERGL'ASSi' ❑ VINYL -LINED ❑ GUNfTE ❑ PREFABRICATED
:POOL' -SF SPA -SF'. SPAATTACHED []YES ❑ NO TOTAL -SF
r RECED BY: TOTAL
Carmnercial or Multi-Famihi Buildinfs with Public Szbimminr Pools requires Department of Enviraumeutal Heath auuroval /`�i1 �QJ, OT AL
i r 1
RE -ROOF EXISTING ROOF TYPE: ❑ BUILT-UP ROOF ❑ASPHALT SHINGLES EJ SHAKES ❑ WOOD SHINGL ❑ T E OTHER (SPECIFY)
REMOVE /REPLACE E] NO IF NO PLYWOOD 3/8" PLYWOOD TYPE: PITCH: ROOF CLASS
❑ YES #'OF LAYERS I THICKNESS ❑ 5/8" OTHER ❑ OSB E]CDX OTHER 12 A
PROPOSED ROOF TYPE: ❑BUILT-UP ROOF ❑ASPHALT SHINGLES ❑ WOOD SHAKES ❑ WOOD SHINGLES ❑ OTHER
*Provide a signed copy of the Cupertino's Tear -Off Policy SF #oEsQUAREs
By my signature below I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I
have read this application and the information I have provided is correct. I have read the Description of Work and! verify itis accurate. I agree
to comply with all applicable local ordinances and state laws relating to building construction. I authorize representatives of Cupertino to
enter the above -identified property for inspection purposes. I acknowledge and authorize all information contained on this application form
to be made available for public record.,,
Signature of Applicant/Agent:, �G �' `t/` a Date:
SUPPLEMENTAL INFORMATION REQUIRED
*New SFD/Second Dwelling Units/Multifamily Dwellings: A Demolition permit is required prior to issuance of a building permit for all new construction.
*Commercial Buildings: Provide a completed Hazardous Materials Disclosure form if any Hazardous Materials are being used as part of this project.
*Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application.
*HOA -Provide a letter of approval from the Home Owner's Association
BldgApp_2017.doc revised 08101117
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT `DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
2 (408) 777-3228 • building@cupertino.org PEMTT=B-
CUPERTINO REV DEF:
I-1 mFw c-ntvSTRt u-rTnv n AnTnrrrnxi I I AI Tf:A ATIn\t IX 1 -I' I I_I AACD M Rr-Rmr I7 rWIUUTNC: PC)nI /CPA
PROJECrADDRFSS APN:
Results Wav 2
OWNER NAME PHONE
E -\FAIL
Roger Anchartechahar 650421-1832
ranchartechaharC\a le.com
5TRE ET ADDR M.
CITY, STATE, ZIP
Lb=malt9ta0sttKW-DDC
I Giw*ALQA 6005014
0 CONTRACTOR NAME ❑ OA:NER-BUILDER
LICENSE NUMBER LICENSETYPE
JCONIPANYNAME
TCG BuilbBs
TCG Builds
835W B
STREET ADDRESS
CRY, STATE, ZIP
8901 RftG3M9*j310&QA8it6000
I mlotitstsQ9195MB5
PHONEPHONEBUS.
E-TL\IL408-582
LIC.
tC6bU3UwwaGTM
ashlim�I@l#wwaGTM -4840
27856
❑ ARCHITECT D OtVNER ❑ OWNER AGENT •❑ CONTRACTOR ACERT❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTACT NAME
E-MAIL
Ashlin Braddock
ash] inb@tcgbuilders.com
STREET ADDRESS
CIN, STATE, ZIP PHONE
890 N McCarthy Blvd Suite 100
Milpitas, CA 95035 408-582-4840
DECRIPTON '
Tenant im robement for -1,100 SF of offices ace to offices and engineering work rooms. Located on the 2nd floor of
existing building.
r
❑SI,VGLE-FAMILY/DUPLEX ❑MULTI -FAMILY ❑ IN'DUSTRIAL D" COMMERCIAL
USE
TYPE
OCC
sQ.FT.
VALUATION (S)
EXISTING US$
I EXISTING SF
NEW FLOOR SF
PORCH
SF DECK SF
I DFNIOSF
STORIES;
TOTAL NET SF
aiili¢e
rili>DO
I 2
Iti71700
REMODEL
BATHROOM ; '
REMODEL KITCHEN
SF
REMODELOTHR GARAGE
❑ ATTACHED
Offic'P'
�,{�
.I {�
SF
SF SF
❑ DETACHED
'�Jt'I
ce
1 jl(0O,
I�y /r�C'fVV
EXISINC]YFS;
1,EICIILER;SECONDSTORY'ADDn10N
' D YES
❑tF5
FIRE SPRINKLERS E3 NO
❑ No❑NO
office
office
DI\'ELLING
SECONDDWF.LUNG QYF•S ❑ATTACHED❑DETACHED OTHER
UNITS a
UNIT ADDITO%�:;.❑ NU S p
office
office
POOLS 'D FI3ERGI.I\55..0 VINYL -LINED ❑ GUNITE []PREFABRICATED
office
office
POOL -SF 51'.i�•SF SPA ATTACHED ❑YES ❑ NO TOTAL -SF
mal uh5157,866
RECEIVED BY:
TOTAL VALUATION:
OOF EXISTINGHQOr.TYPF.:❑HUILT-UP ROOF❑ ASPHALTSHINGLES❑WOODSHAKES❑N'OODSHINGLESQTILC•
O-TtiER(SPECIFY) office
VEJREI?LACE NO
�
�IFNO
PLYSYOOD rTIS,,
❑ ❑ •
PI,YIVOOD7YPE:
PITCH:
'❑
ROOFCLASS�y
Or LAYERS
TIiICKNFSS ❑ 518" OTHER
❑OSN ❑ CDX OTHER
qr�
' 1G
A
SEDROOFTYI'E:❑BUILT-UPROOF❑ASPHALTSHINGLESDR'OODSHAKFSD4VOODSHI,\C.LEiS ❑OTHER
ide asigned copy [lie Cupertino's Tear -Off Policy
of SF ;ofSQUARES
y signature belbiv I certi[�' to each of the following: I am the properly owner or authorized agent to act on the property owner's behalf• I
read this applicatii)n and the information I have provided is correct. 1 have read the Descriptionof Work and verify it is accurate. I agree
1.
mplywith all applicable, local ordi �nces d state I \ s relating l' building construction. I authorize representatives of Cupertino to
thelaiiove-identified property or insp ion pur ose . %VI a and authorize all information contained on this application form
made availablefor public re ord.
ature'of ApplicantlAgenC1
SUPPLEMENTAL INFORMATION REQUIRE
Ne v SFD/Second Dtvolling Units/Multifamily Dwellings: A Demolition permit is required prior to issuance of a building permit forlall new construction.
'Commercial Buildings'I Provide a completed Hazardous Materials Disclosure form if any Hazardous Materials are being used as pait of thus project.
'Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application.
•HOA-Proi'%de a letters df approval from the Home Owner's Association
Bldg,4pp_3017.doc revised 08+01117
STATE OF CALIFORNIA
INDOOR LIGHTING
CEC-NRCI-LTI-01-E (Revised 01/16)
.f 1'.
FF
CAI IFORNIA NR( Y MRAN R 10ri
CERTIFICATE OF INSTALLATION NRCI-LTI-01-E
Indoor Lighting Page 1 of 2
Project Name:A04 R -W 07.Enforc
nt gency: q
gh
N ¢ ®�
Project Address:
--r
city
q F
'"—rmit
ZiPCode: p01q
GENERAL INFORMATION
DATE OF BUILDING PERMIT
Applicable Sheets or Pages, Tables,
Schedules, etc.
PERMIT NUMBER.
Date:
BUILDING TYPE.]
Nonresidential
❑ High -Rise Residential (common area)
❑ Hotel/Motel (Common Area)
PHASE OF CONSTRUCTION
❑ New Construction
❑ Addition
[ Alteration
❑ Unconditioned
SCOPE OF RESPONSIBILITY
Enter the date of approval by enforcement agency of the Certificate of Compliance that provides the
Applicable Sheets or Pages, Tables,
Schedules, etc.
specifications for the energy efficiency measures for the scope of responsibility for this Installation
Date:
Certificate.
In the table below identify all applicable construction documents that specify the requirements for the scope of responsibility
reported by this Installation Certificate (continued).
Document Title or Description
Applicable Sheets or Pages, Tables,
Schedules, etc.
Date Approved by
Enforcement Agency
Add Row
I Rerr)ove Last
CA Building Energy Efficiency Standards - 2016 Nonresidential Compliance
January 2016
STATE OF CALIFORNIA
INDOOR LIGHTING
CEC-NRCI-LTI-01-E (Revised 01/16)
CERTIFICATE OF INSTALLATION
NRCI-LTI-01-E
Indoor Lighting
Page 2 of 2
Project Name:) ,
(J-
Enfor men Agency: Q�' &
'
emit Nu er:
-.a
Project Add I V
City; a} _
Zip Code: 's—ol
DOCUMENTATION AUTHOR'S DECLARATION STATEMENT
1. I certify that this Certificate of Installation documentation is accurate and complete.
Documentation Author Name: \\ (( �
O o
Documentation Au or1signature`A
i6 /
Documentation Author Company Name: /t
/
Date Signed: �" ,
tij x
Address:. -
CEA Certification Identification (If applicable):
City/State/Zip: g S-0 I
Phone: ^ -. S
�J
RESPONSIBLE PERSON'S DECLARATION STATEMENT
I certify the;following under penalty of perjury, under the laws of the State of California:
1. The information provided on this Certificate of Installation is true and correct.
2: I 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 Installation and attest to the declarations in this statement (responsible builder/installer),
otherwise I am an authorized representative of the responsible builder/installer.
3. The constructed or installed features, materials, components or manufactured devices (the installation) identified on this
Certificate of Installation conforms to all applicable codes and regulations, and the installation conforms to the requirements
given on the plans and specifications approved by the enforcement agency.
4. 1 reviewed a copy of the Certificate of Compliance approved by the enforcement agency that identifies the specific requirements
for the scope of construction or installation identified on this Certificate of Installation, and I have ensured that the requirements
that apply to the construction or installation have been met.
5. 1 will ensure that a completed signed copy of this Certificate of installation 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
completed signed copy of this Certificate of Installation is required to be included with the documentation the builder provides to
the building owner at -occupancy.
Responsible Builder/Installer Name:
Responsible Builder/Installer Signatures
Company Name: (Installing Subcontractor or General Contractor or Builder/owner)
Position With Company (Title):
Address:
CSLB License: _
City/State/Z,ip;
Phone
Date Signed:
CA Building Energy Efficiency Standards -2016 Nonresidential Compliance January, 2016
STATE OF CALIFORNIA
ENERGY MANAGEMENT CONTROL SYSTEM OR LIGHTING CONTROL SYSTEM
CEC-NRCI-LTI-02-E (Revised 01116) CAi iFn RNIA FmF=Pr.y cnAAnAFSSinri
- — - - -
CERTIFICATE OF INSTALLATION
-- ------
NRCI-LTI-02-E
-
Energy Management Control System or Lighting Control System
(Page 1 of 6)
Project Name:Apo-.
Enforcement Agency:
da P it Nu beY• -
f
Project Address: u S
City:
Zipe ade: 10 (LI
GENERAL INFORMATION
`Enter the date of approval by enforcement agency of the Certificate of Compliance that provides
OF BUILDING PERMIT
PERMIT#
32 -BUDATE
1-7 — 10132 -
BUILDING
ILDING TYPE
[' 'Nonresidential
❑ High -Rise Res (Common Area)
❑ Hotel/Motel (Common Area)
PHASE OF
CONSTRUCTION
❑ New Construction
❑ Addition
El Alteration
ElUnconditioned
SCOPE -OF RESPONSIBILITY
`Enter the date of approval by enforcement agency of the Certificate of Compliance that provides
Date:
the specifications for the energy efficiency measures for the scope of responsibility for this
' 1
Installation Certificate.
0
Requirements in the Standards:
§130.4(b) Before an Energy Management Control System (FMCS), or Lighting Control System can be recognized for
compliance with the lighting control requirements in Part b of Title 24, the person who is eligible under Division 3 of the
Business and Professions Code to accept responsibility for the construction or installation of features, materials,
components, or manufactured devices shall sign and submit this Installation Certificate.
If any of the requirements in this Installation Certificate fail the Energy Managem System or Lighting Control
System installation requirements, these options for controlling lighting sh n t be -recognized fo
corn with the
Building Energy Efficiency Standards, 1517
Check all that apply-
PART 1 What type of Lighting Control System has been instal ed?417
A. Energy Management Control System (FMCS) -Is a computeriz . \d contro s�designd toregulate the
_energy consumption of a building by controlling the operation of ergy consuming systems, such as the heating,
ventilation and air conditioning (HVAC), lighting, and water heating s stems, and is capable of monitoring
environmental and system loads, and adjusting HVAC operations in order to optimize energy usage and respond
to demand response signals.
❑ The Energy Management Control System has been installed to function as a lighting control required by Part
6 and functionally meets all applicable requirements for each application for which it is installed, in
accordance with Sections 110.9, 130.0 through 130.5, 140.6 through 150.0, and 150.2; and complies with
Reference Nonresidential Appendix NA7.7.2.
The EMCS has been separately tested for each respective lighting control system for which it is installed to
function as.
B. Lighting Control System -Requires two or more components to be installed in the building to provide all of
the functionality required to make up a fully functional and compliant lighting control.
D( The installed Lighting Control System complies with the requirements checked below; and all components of
the system considered together as installed meet all applicable requirements for the application for which
they are installed as required in Sections 130.0 through 130.5, Sections 140,6 through 140.8, Section 141.0,
and Section 150.0(k).
CA Building Energy Efficiency Standards - 2016 Nonresidential Compliance January 2016
STATE OF CALIFORNIA
ENERGY MANAGEMENT CONTROL SYSTEM OR LIGHTING CONTROL SYSTEM
CEC-NRCI-LTI-02-E (Revised 01/16) CALIFORNIA ENERGY COMMISSION
CERTIFICATE OF INSTALLATION
NRCI-LTI-02-E
Energy Management Control System or Lighting Control System
(Page 2 of 6)
Project. Name; - - -
Enforcement Agency: - -
Permit Number.
Project Address: - -
City:
Zip Code:
PART 2 Lighting Control_ Functional requirements; Check all that apply when verifying the installation of an EMCS or
Lighting Control System.
A. All lighting controls and equipment have been installed in accordance with the manufacturer's instructions.
B. The manufacturer has provided instructions for calibration.
C. If indicator Eights are integral to any components, such indicator lights consumes no more than l watt of
power per indicator light.
D. Components that are regulated by the Title 20 Appliance Efficiency Regulationshave been certified to the
Energy Commission.
E. The EMCS or Lighting Control System functions as one or more of the Time -Switch Lighting Controls checked`
below, and complies with all of the following requirements:
[ 1. Automatic Time -Switch Controls meeting all requirements for Automatic Time Switch Control devices in
the Title 20 Appliance Efficiency Regulations, including the requirements below:
a; Residential automatic time -switch controls have program backup capabilities that prevent the
loss of the device's schedule for at least 7 days, and the device's date and time for at least 72
hours if power is interrupted.
b. Commercial automatic time -switch controls meet the following requirements:
i. Has program backup capabilities that prevent the loss of the device's schedule for at least
7 days, and the device's date and time for at least 72 hours if power is interrupted
ii. Is capable of providing manual override to each connected load and shall resume normally
scheduled operation after manual override is initiated within 2 hours for each connected
load; and
iii. Incorporates an automatic holiday shutoff feature that turns off all connected loads for at
least 24 hours and then resumes normally scheduled operation.
❑ 2. Astronomical Time -Switch Controls meeting all requirements for Astronomical Time -Switch Control
devices in the Title 20 Appliance Efficiency Regulations, including the requirements below:
a. Meets the requirements of an automatic time -switch control;
b. Has sunrise and sunset prediction accuracy within plus -or -minus 15 minutes and timekeeping
accuracy within 5 minutes per year;
c. Is capable of displaying date, current time, sunrise time, sunset time, and switching times for
each step during programming;
d. Has an automatic daylight savings time adjustment; and
e. Has the ability to independently offset the on and off for each channel by at least 99 minutes
before and after sunrise or sunset.
Fj 3. Multi -Level Astronomical Time -Switch Controls, in addition to meeting all of the requirements for
Astronomical Time -Switch Controls, includes at least 2 separately,programmable steps per zone.
F. The EMCS or Lighting Control System functions as one or more of the Daylighting Controls listed below:
CA Building Energy Efficiency Standards - 2016 Nonresidential Compliance January 2016
STATE OF CALIFORNIA
ENERGY MANAGEMENT CONTROL SYSTEM OR LIGHTING CONTROL SYSTEM
CEC-NRCI-LTI-02-E (Revised 01/16) CALIFORNIA ENFRGY MIUMIssION
CERTIFICATE OF INSTALLATION
NRCI-LTI-02-E
Energy Management.Control System or Lighting Control System
(Page 3 of 6)
Project Name: - - -
Enforcement Agency: _ -
- - - Permit Number;
Project Address: - - -
city:
'Zip Code:
El 1. Automatic Daylight Controls meet all requirements for Automatic Daylight Control devices in the Title 20
Appliance Efficiency Regulations, including the following:
a. Is capable of reducing the power consumption in response to measured daylight either directly or
by sending and receiving signals;
b. If the system includes a dimmer, complies with the Dimmer Control :device requirements in the
Title 20 Appliance Efficiency Regulations.
c. Automatically return to its most recent time delay settings within 60 minutes when put in
calibration mode;
d. Has a set point control that easily distinguishes settings to within 10% of full scale
adjustment;
e. Has a light sensor that has a linear response within 5% accuracy over the range of
illuminance measured by the light sensor;
f. Has a light sensor that is physically separated from where the calibration adjustments are made,
or is capable of being calibratedin a manner that the person initiating the calibration is remote
from the sensor during calibration to avoid influencing calibration accuracy; and
g. Complies with the Title 20 requirements for photo controls if the system contains a ,photo control'
component.
❑ 2. Photo Controls meet all requirements for Photo Control devices in the Title 20 Appliance Efficiency
Regulations, including the following that it does not have a mechanical device that permits disabling of the
control.
K G. The EMCS or Lighting Control System functions as a Dimmer and meets all requirements fora Dimmer Control
device in the Title 20 Appliance Efficiency Regulations, including the following:
1. Is capable of reducing power consumption by a minimum of 65% when the dimmer is at its lowest
level;
2. Includes an off position which produces a zero lumen output; and
3. Does not consume more than 1 watt per lighting dimmer switch leg when in the'off position.
4. Dimmer controls that can directly control lamps provide electrical outputs to lamps for reduced flicker
operation through the dimming range so that the light output has an amplitude modulation of less than
30% for frequencies less than 200 Hz without causing premature lamp failure.
5. If designed for use in three way circuits is capable of turning lights off, and to the level set by the
dimmer if the lights are off.
R] H. The EWICS or Lighting Control System meets the following requirements:
1. Is capable of automatically turning off controlled lights in the area no more than 30 minutes after the
area has been vacated;
2. Allows all lights to be manually turned off regardless of the status of occupancy; and
3. Has a visible status signal that indicates that the device is operating properly, or that it has failed or
malfunctioned. The visible status signal may have an override switch that turns off the signal.
4. All occupant sensing devices that utilize ultrasonic radiation for detection of occupants meet the
Ultrasound Maximum Decibel Values in the Title 20 Appliance Efficiency Regulations
5, All occupant sensing devices that utilize microwave radiation for detection of occupants meet the
radiation requirements in the Title 20 Appliance Efficiency Regulations
6. Occupant sensing devices incorporating dimming comply with the requirements for dimmer controls in
the Title 20 Appliance Efficiency Regulations
CA Building Energy Efficiency Standards 2016 Nonresidential Compliance January 2016
STATE OF CALIFORNIA
ENERGY MANAGEMENT CONTROL SYSTEM OR LIGHTING CONTROL SYSTEM
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CERTIFICATE OF INSTALLATION
NRCI-LTI-02-E
Energy Management Control System or Lighting Control System
(Page 4 of 6)
Project Name: - _
Enforcement Agency:
Permit Number:
Project Address:
City: _ -
Zip. Code:
7. The FMCS or Lighting Control. System functions as one or more of the Occupant Sensing Controls
Checked Below:
a. Occupant Sensors meeting all applicable requirements for Occupant Sensor Control devices in
the Title 20 Appliance Efficiency Regulations.
b, Motion Sensors meeting all applicable requirements for Motion Sensor Controls devices in the
Title 20 Appliance Efficiency Regulations, including that motion sensors are rated for outdoor use.
c. Vacancy Sensors meeting all applicable requirements for Vacancy Sensor Controls devices in
the Title 20 Appliance Efficiency Regulations, including the following:
i. Does not turn on lighting automatically and does not incorporate DIP switches, or other
manual means, for conversion between manual and automatic functionality;
ii. Has a grace period of no more than 30 seconds and no less than 15 seconds to turn on
lighting automatically after the sensor has timed out; and
iii. Does not have an override switch that disables the sensor.
d. Partial -ON Sensors meeting all applicable requirements for partial on sensing devices in the
Title 20 Appliance Efficiency Regulations, including the following:
i. Has two poles each with automatic -off functionality;
ii. Has one pole that is manual -on and does not incorporate DIP switches, or other manual
means, for conversion between manual and automatic functionality; and
iii. Has one pole that is automatic -on and is not be capable of conversion by the user to
manual -on functionality.
0 e. Partial -OFF Sensors meet all applicable requirements for partial off sensing devices in the Title
20 Appliance Efficiency Regulations, including the following:
i. Has two poles;
ii. Has one pole that is manual -on and manual off; and
iii. Has one pole that is automatic -on and automatic -off and is not capable of conversion by
the user to manual -on only functionality.
f. Occupant Sensing Control systems consist of a combination of single or multi-level Occupant,
Motion, or Vacancy Sensor Controls, and all components installed to comply with manual -on
requirements are not capable of conversion by the user from manual -on to automatic -on
functionality.
CA Building Energy Efficiency Standards -2016 Nonresidential Compliance January 2016
P
STATE OF CALIFORNIA
ENERGY MANAGEMENT CONTROL SYSTEM OR LIGHTING CONTROL SYSTEM ,
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CERTIFICATE OF INSTALLATION
NRCI-LTI-02-E
Energy Management Control System or Lighting Control System
(Page 5 of 6)
Project Name:
Enforcement Agency: -
Permit Number:
Project Address: -
City:
Zip Code:
PART 3 Requirements for which the control is being installed to complied with:
Identify all requirements in the Standards for which the EMCS or Lighting Control System is installed to function as and
complies with:
Check all that are applicable
A. Section 130.1(a) Area Controls.
B. Section 130.1(b) Multi -Level Lighting Controls
C. Section 130.1 (c) Shut -OFF Controls
El D. Section 130.1 (d) Automatic Daylighting Controls.
❑ E. Section 130.1 (e) Demand Responsive Controls.
El F. Section 130.5 (d) Circuit Controls for 120 -Volt Receptacles.
If installed to qualify for a Power Adjustment Factor, submit this Installation Certificate in addition to the PAF
Installation Certificate.
❑ G. To qualify for the PAF for a Partial -ON Occupant Sensing Control in TABLE 140.6-A.
❑ H. To qualify for the PAF for an occupant sensing control controlling the general lighting in large open pian:office
areas above workstations, in accordance with TABLE 140.6-A
❑ 1. To qualify for the PAF for a Manual Dimming System PAF or a Multiscene Programmable Dimming System PAF in
TABLE 140.67A
❑ J. To qualify for the PAF fora Demand Responsive Control in TABLE 140:6-A
K. To qualify for the PAF for Combined Manual Dimming plus Partial -ON Occupant Sensing Control in TABLE 140.6-A
CA Building Energy Efficiency Standards - 2016 Nonresidential Compliance January 2016
STATE OF CALIFORNIA
ENERGY MANAGEMENT CONTROL SYSTEM OR LIGHTING CONTROL SYSTEM
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CERTIFICATE OF INSTALLATION
NRCI-LTI-02-E
Energy Management Control System or Lighting Control System
(Page 6 of 6)
Project Name: - - - - ":
Enforcement Agency:
Permit Number:
Project Address:
City:
Zip. Code:
DOCUMENTATION AUTHOR'S DECLARATION STATEMENT
1. 1 certify that this Certificate of Installation documentation is accurate and complete.
Documentation Author Name: --
0 -
Documentation Author Signature:.
Documentation Author Company Name: L��-Dae
Signed: i/
Address: i `� y' sr
CEA Certification Identification (If applicable): y g g
City/State/Zip: •�'�`" .,
< • (�. � 5 (. i �'
Phone:
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RESPONSIBLE PERSON'S DECLARATION STATEMENT
I certify the following under penalty of perjury, under the laws of the State of California:
1. The information provided on this Certificate of Installation is true and correct.
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 Installation and attest to the declarations in this statement (responsible builder/installer),
otherwise I am an authorized representative of the responsible builder/installer.
3. The constructed or installed features, materials, components or manufactured devices (the installation) identified on this
Certificate of installation conforms to all applicable codes and regulations, and the installation conforms to the requirements
given on the plans and specifications approved by the enforcement agency.
4. I reviewed a copy of the Certificate of Compliance approved by the enforcement agency that identifies the specific requirements
for the scope of construction or installation identified on this Certificate of Installation, and I have ensured that the requirements
that apply to the construction or installation have been met.
5. 1 will ensure that a completed signed copy of this Certificate of Installation 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
completed signed copy of this Certificate of Installation is required to be included with the documentation the builder provides to
the building owner at occupancy.
Responsible Builder/Installer Name:
Responsible Builder/Installer Signature:
Company Name: (Installing Subcontractor or General Contractor or
Position With Company (Title):
Builder/Owner)
Address: -
CSLB License:
City/State/Zip:
Phone
Date Signed:
CA Building Energy Efficiency Standards - 2016 Nonresidential Compliance
January 2016