15110034CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19379 STEVENS CREEK BLVD
CONTRACTOR: CORPORATE SIGN PERMIT NO: 15110034
SYSTEMS, INC
OWNER'S NAME: MAIN STREET CUPERTINO AGGREGATOR
OWNER'S PHONE: 6503441500
2464 DE LA CRUZ BLVD DATE ISSUED: 12/08/2015
SANTA CLARA, CA 95050 PHONE NO: (408)292-1600
LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
License Class Lic. # N�S
�—
MAIN STREET -INSTALL I2 SIGNS TOTAL (VARIOUS
LOCATIONS) - 3 ILLUMINATED; 4 NON -ILLUMINATED
Contractor !'iii' -{>CW' pT Std S'I�( S Date_ tl-OD ` L
WALL
I hereby affirm that I am licensed under the provisions of Chapter 9
SIGNS AND 5 ILLUMINATED DIRECTIONAL SIGNS
(commencing with Section 7000) of Division 3 of the Business & Professions
Code and that my license is in full force
and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate
of consent to self -insure for Worker's
Compensation, as provided for by Section 3700 of the Labor Code, for the
erformance of the work for which this permit is issued.
v e and will maintain Worker's Compensation Insurance, as provided for by
Sq. Ft Floor Area: Valuation: $87000
0
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
APN Number: 31620109,19379 Occupancy Type:
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating
PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned
WITHIN 180 DAYS OF PERMIT ISSUANCE
property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
granting of this Additionally,
.OR
180 DAYS FROM LAST CALLED INSPE T JON.
le -
permit. the applicant understands and will comply
with '
Issued by: m Date: dM 12-
all non -point sou re ula s per the Cupertino Municipal Code; Section
9.18.
Signature Date' °! S
RE -ROOFS:
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
0 OWNER -BUILDER DECLARATION
inspection. J
I hereby affirm that I am exempt from the Contractor's License Law for one of
Signature of Applicant: Date:
the following two reasons: I
I, as owner of the property, or my employees with wages as their sole compensation,
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
will do the work, and the structure is not intended or offered for sale (Sec.7044,
Business & Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractors to
HAZARDOUS MATERIALS DISCLOSURE
construct the project (Sec.7044, Business & Professions Code).
I have read the hazardous materials requirements under Chapter 6.95 of the
I hereby affirm under penalty of perjury one of the following three
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
declarations:
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
I have and will maintain a Certificate of Consent to self -insure for Worker's
Health & Safety Code, Section 25532(a) should I store or handle hazardous
Compensation, as provided for by Section 3700 of the Labor Code, for the
material. Additionally, should I use equipment or devices which emit hazardous
performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,
air contaminants as defined by the Bay Area Air Quality Management District I
will maintain compliance with the Cup n unicipal Code, Chapter 9.12 and
the Health
as provided for by
Section 3700 of the Labor Code, for the performance of the work for which this
& Safety Code, Sections 0 5 , and 25534.
permit is issued.
Owner or authorized agent: Date: V= O ,t
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 Califomia. 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
forthwith comply with such provisions or this be deemed
I hereby affirm that there is a construction lending agency for the performance of
for
permit shall revoked.
work's which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is °
Lender's Address
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
granting of this permit. Additionally, the applicant understands and will comply
I understand my plans shall be used as public records.
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Licensed Professional
Signature Date
CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
ADDRESS: 19379 Stevens Creek Blvd
DATE: 12/08/2015 REVIEWED BY: Paul
APN: 31620109.19379BP#: -
VALUATION: $87,000
FPERMIT TYPE: Building Permit £ £1.: £ 1£;:` .r x,£:
PRIMARY
USE: Sign PENTAMATION
PERMIT TYPE: 1 CEAP5
WORK Main Street - Install 12 Signs Total Various Locations - 3 Illuminated; 4 Non -Illuminated Wall Signs J
SCOPE and 5 Illuminated Directional Signs
SIGN TYPE
Directional Sign
Wall Sign, Electric
FEE ID
1SIGNDIRECT
1SIGNWELEC3
anu are
QTY/FEE
QTY
5
P1,171
SIGN FEE
$1,430
0.0
hrs
$858
Wall Sign, Non -Electric
1SIGNWNONE
4
$3;432.00
$1,144
TOTALS: I ) $3,432.00
x # Branch Circuits 1 $48.00
x x;
IESIGN Elec. Permit Fee: IEPERMIT
Other Elec. Insp. 0.0 $48.00
19.
NOTE This estimate does not include fees due to Other Departments (i.e. Planning, Puhlic Works, Fire, Sanitary Sewer District. Schnnl
V. --.,y
FEE ITEMS (Fee Resolution 11-053 F` ' 7.1113)
"• u,"umuii ueuiucote
FEE
anu are
QTY/FEE
onlY an estimate. Contact the De t or addn'l info.
MISC ITEMS
P1,171
Suppl. PC Fee: E) Reg. 0 OT
0.0
hrs
$0.00
Pen -nit Fee:
$3;432.00
Suppl. Insp. Feer Reg. 0 OT
0.0
hrs
$0.00
PME Unit Fee:
$48.00
PME Permit Flee:
$48.00
Work Without Permit? 0 Yes (E) No
$0.00
Sign Master Plan: 0 Yes e) No
$0.00
a
Travel Documentation Fee: 1TRAVDOC
$48.00
Strong Motion Fee: 1BSEISMICO
$24.36
Select an Administrative Item
1
Bldg Stds Commission Fee: IBCBSC
$4.001
SUBTOTALS
$3,604.361
,:
$0.00,.. TOTAL FEEt
$3,604.36
Revised: 10/01/2015
a
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: ,19379 STEVENS CREEK BLVDDAT E: 11/0612015 REVIEWED BY: MELISSA
131020109.19379
:,BP#:
*VALUATION: $87,000
*PERMIT TYPE Building Permit CILCE
TYPE:
PRIMARY
PENTA ATION
--�E
PERMIT
TYPE.
USE NTAMATION
ja PERMIT TYPE: 1 CEAP5
Ww- STREET- - I - 'A
WORK MAIN INSTALL SIGNS TOTAL (VARIOUS LOCATIONS), 3 ILLUMINATED, 4
SCOPE '.:QLUMINATED WALL SIGNS & OILLUMINATED DIRECTIONAL SIGNS
,
SIGNTYPE -
FEE ID El QTY SIGN FEE
1SIGNDIRECT
10 $2,860
's
ISIGNWELEC
3
$858
Wa11;Sxgri,Non;Eh6:ric ISIGNWNONE
4 $1,144
TOTALS:
$4,862. 00
62 M,
044NNW
rM
QTY/FEE
71
X ur�`k v
1,11.b. Pian Check
# Branch C 1 $48.00
Circuits
j
P,rmit
1,ESIGAr Fee: ]EPERMIT
Elec. Pennit
$0.00
odler." 1,un 15 11
Other Elec. Insp.L20 $48.00
-I
k, :. Insp. fee:
$4,862.00
Suppj 111sp-1 fj- 0 OT
Fee )�eg..
flut tactuuejees uue to urner"epar.-mPlanning, (Le. anning, PUNIC WorksPire, Sanitaq .Sewer District, School
�. 4" 1 "'
District.'-.
FEC.,� IT, 9M S.1 -0539 7/1/1
Bi�)��s6lution 11 ff. 3)
FEE
QTY/FEE
MISC ITEMS
uOpl- p Fee (E) Re 0 OT
0,Qhrs
$0.00
Permit Fee
$4,862.00
Suppj 111sp-1 fj- 0 OT
Fee )�eg..
0. 0
hrs
$0.00
PME11it:F 'e-
$48.00
PME ;Permit Fee
$48.00
Permit?
Work-:W,x,#iq, 0 Yes (D No
$0.00
sigMaster Pjan::,s-, 0 Yes (F) No
$0.00
A
Travdl Documentation Fee: ITRAVDOC
$48.00
Strop' on Fee' IBSEISMICO
1144
$24.36
Select an Administrative Item
`§id,sinissio, n Fee: IBCBSC
$4.00
Tmw �,K- K%
- EMN M
2 z " -
$5,034.361
gma-g-
$0.00 _R11"d
$5,03 4.36
6]
3
Revised: 10101/2015
7
CUPERTINO
SIGN PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 •FAX (408) 777-3333 • building(akupertino.org
S
PROJECT ADDRESS / �'A �'Q , /
/ Q '7
APN # . / /g ZO to
(_I5UD
OWNERNAME 5AND A-11 FV_09XC`/' //VN�P'cD.gl
`J2%
PHONE 3O _sL �4
E-MAIL
STREET ADDRESS
T
s om 111 �tb 1 sTE 244
CITY, STATE,, ZIP . iJljLWL.p /L� � / C& p jTy/w �•
0 N,
FAX
CONTACT NAME "1,X00
hL"'goo
PHONE ^ M
E-MAIL
1 N'if; l�J 1 J•
STREET ADDRESS 24A W 4 wo, R, ,1t)
CITY,STATE, ZIP SMTA cL& I c -A N50
FAX 0
-117- _1(913
❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME ' � 0 1 �• t ` , ` (� C1 ('
W/iW/ni",o'jFDIV
LICENSE NUMBER i& C O, b
JJp
LICENSE C, L�
BUS. LIC #
�{W �,SJTt SJ
COMPANY NAME
•TYPE
E-MAILA�(O
p� �
WF'[VRT�oN�•��%
/- -�j
FAX /L/ri•n(a 'f •��o 7S
^��(�! �1�1i�•
STREET ADDRESS 741p+ �E ma D��'J•
VK•
CITY, STATE, ZIP 43WIla O A� ^ I `A pso s
W1 WK�"H (/N _I
PHONE
lboo
ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC#
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK C1`_' 1` TIe 1 t`*1f'�RI,�_ 1 t. �,t�t�D 1 ►�iU A'f 'Nf�+.J t�ET1A�t,�t�
J V1UV IV ` YMw)` UST. C1t W
^ wVG (o U-5„i
SI hs T1No
74
o CC,*0 ns
USE OF ❑ SFD or Duplex ❑ Multi -Family
ILLUMINATED
SIGN TYPE
NO. OF
SIGN AREA
VALUATION
STRUcrm: Commercial
({Y,j/N)
(CODE)
SIGNS
(SQQ.Fr.)
(S)
`
-j
”
35.1?)
`' 13
$ Q Ooo
SIGN TYPE CODES:
1`�
,
•
1
B - BANNER SIGN M - MONUMENT (GROUND) SIGN
BE - BLADE SIGN P - PROJECTING SIGN
Y
r 1
5
2Ca
D - DEVELOPMENT ID SIGN SP - SPECIAL EVENT BANNER
DI - DIRECTIONAL SIGN T - TEMPORARY
1
E - ELECTRONIC W - WALL SIGN
1�
2
i•
Zj.,
4 X11000
1
READERBOARD WI - WINDOW SIGN
RECEIVED BY:
TOTAL VALUATION:
j Opo
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 pro ed ' rre I. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to bu' ing st ton. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes.
Signature of Applicant/Agent: Date: I1•Ds •(S
SUPPLEMENTAL INFORMATION REQUIRED
OFFICE USE ONLY
PLAN CHECK TYPE
ROUTING SLIP
Site Plan
❑ OVER-THE-COUNTER
❑ BUILDING PLAN REVIEW
Elevations
Sign Details - including UL listing(s) applicable
EXPRESS
❑ PLANNING PLAN REVIEW
Structural Calculations (if applicable)
�❑l
STANDARD
❑ OTHER:
Copy of Planning Approval Letter or Meeting with Planning prior to
LARGE
submittal of Building Permit application.
❑ MAJOR
SignApp_2011.doc revised 03/31/11
:VATE OF CALIFORNIA
SIGN LIGHTING
F-1
EC-NRCC-LTS-01-E(Revised 06/14) CALIFORNIA ENERGY COMMISSION
CERTIFICATE OF COMPLIANCE NRCC-LTS-01-E
Sign Lighting (Page 1 of 5)
Project Name: •, Date Prepared:
�.i r� )..� W�' �'fi l r) -' 10 -V1. IS'
Project Address:
Location of Sign '.Outdoor Signs ❑ Indoor Signs
Phase of Sign Construction New Signs ❑ Sign Alterations
Type of Lighting Control New Lighting Controls ❑ Replaced Lighting Controls lg,'iVot Installing Lighting Controls
This Certificate of Compliance includes the following components (check all that apply)
❑ Mandatory Measures (Lighting Controls) 5' Maximum Allowed Lighting Power ❑ Specific Lighting Sources
1. Mandatory Sign Lighting Controls
NOTES:
1.
The same responsible person may install both the sign lighting power and the sign lighting controls, or a different responsible
person may install the sign lighting controls than the responsible person installing the sign lighting power.
2.
The Mandatory Measures (sign lighting controls) are required for compliance with the sign lighting Standards. If the person
responsible for installing the sign lighting power is not also responsible for the sign lighting controls, then the owner of the sign,
general contractor, or architect shall be responsible to have the sign lighting controls installed.
3.
If more than one person has responsibility for compliance, each responsible person shall prepare and sign a Certificate of
Compliance and an Installation Certificate applicable to the portion of construction for which they are responsible, alternatively,
the person with chief responsibility for construction shall prepare and sign the Certificate of Compliance Declaration Statement
for the entire construction.
la.
Statements of Responsibility: Any person signing the Certificate of Compliance Declaration Statement on this NRCC-LTS-01-E
shall
complete Part 1a. Check Yes or No for all of the following statements:
1 have responsibility for installing the sign lighting controls
11
❑ Yes, complete parts 1a and 1b of this form 39 No, complete part 1a of this form
There are no existing sign lighting controls and I will be installing compliant sign lighting controls
2
❑ Yes Z No
There are no existing sign lighting controls and someone else will be responsible to install compliant sign lighting controls
3
1$Yes ❑ No
There are existing sign lighting controls that do not comply with the applicable provision of §110.9 and §130.3 and I will be
4
installing compliant sign lighting controls
❑ Yes Ag No
There are existing sign lighting controls that do not comply with the applicable provision of §110.9 and §130.3 and someone
5
else will be responsible to install compliant sign lighting controls
1 ❑ Yes No
r A 6uildinq Department
V.NOV 195 2111)i5
REViFvvED f -OR CODE COMPLIANCE
KevieweO By. '-� h 4rew
RECEIVEIM
BY
OFFICE COPY
CA Building Energy Efficiency Standards - 2013 Nonresidential Compliance June 2014
:TATE OF CALIFORNIA
SIGN LIGHTING
CEC-NRCC-LTS-01-E Revised 06/14 CALIFORNIA ENERGY COMMISSION
CERTIFICATE OF COMPLIANCE NRCC-LTS-01-E
Sign Lighting (Page 2 of 5)
Project Name: M^N 1a 5 „,��y� Np Date Prepared: (lei , 15
(�j vl�. � l
1b. Mandatory Sign Lighting Controls
If the person signing the Certificate of Compliance Declaration Statement on this NRCC-LTS-01-E is responsible for complying with
the sign lighting control requirements, that person shall answer all of the following questions:
If there are construction documents, indicate where on the building plans the
mandatory measures (sign lighting control) note block can be located:
§130.3(a)1. All indoor sign lighting is controlled with an automatic time -switch control or astronomical time-
Y
N
NA
1
switch control.
❑
❑
§130.3(a)2A. All outdoor sign lighting is controlled with a photocontrol in addition to an automatic time-
Y
N
NA
switch control, or an astronomical time -switch control.
Id
❑
❑
2
EXCEPTION to Section 130.3(a)2A: Outdoor signs in tunnels, and signs in large permanently covered outdoor
Y
NA
areas that are intended to be continuously lit, 24 hours per day and 365 days per year.
❑
§130.3(a)2B. All outdoor sign lighting that is ON both day and night is controlled with a dimmer that provides
the ability to automatically reduce sign lighting power by a minimum of 65 percent during nighttime hours.
Y
N
NA
Signs that are illuminated at night and for more than 1 hour during daylight hours shall be considered ON both
❑
3
day and night.
EXCEPTION to Section 130.3(a)2B: Outdoor signs in tunnels and large covered areas that are intended to be
Y
NA
illuminated both day and night.
❑
Iq
§130.3(a)3. Demand Responsive Electronic Message Center Control. An Electronic Message Center (EMC)
Y
N
N/A
having a new connected lighting power load greater than 15 kW has a control installed that is capable of
❑
❑
4
reducing the lighting power by a minimum of 30 percent when receiving a demand response signal.
EXCEPTION to Section 130.3(a)3: Lighting for EMCs that is not permitted by a health or life safety statute,
Y
NA
ordinance, or regulation to be reduced by 30 percent.
❑
Field Inspector Notes:
CA Building Energy Efficiency Standards - 2013 Nonresidential Compliance June 2014
TATE OF CALIFORNIA
SIGN LIGHTING
F-73
CEC-NRCC-LTS-01-E(Revised 06/14) CALIFORNIA ENERGY GUMMISSIUN
CERTIFICATE OF COMPLIANCE NRCC-LTS-01-E
Sign Lighting (Page 3 of 5)
Project Name: �^Date Prepared: U S
V Fi`L 1 '11- 1
2. Maximum Allowed Lighting Power Method of Compliance
Certificate of Compliance and Field Inspection Energy Checklist
Complete this part if there are signs using the maximum allowed lighting power method of compliance. (Complete part 3 of
this Certificate of Compliance if there are signs using the Specific lighting sources method of compliance)
A
B
C
D E F G
H
I
J
Symbol
Or Code
Description of the Sign
OPTIONAL—Energy
Verified Label (see
instructions below)
Allotted Watts
Design Watts
Complies
YIN
Filed Inspector
Check that sign
complies
m C
bC0 N X E
in c w
NU x
N (•() v
O fV
Q =- w Q
CC
C
mY
FO- 3
VI
w
a
a
0
U
❑
y
❑
❑
❑
i3`t _T
W.,05
Zv 1
*11AIM a IM11rJi) W ,
❑
A,
3 Cl
Y
❑
Cox COU►J M
❑
i�, 3 �
t2 24 (a
2 .45
❑
❑
:i.� S
❑
WM r W Owd
❑
i� :1.2
❑
❑
❑
❑
❑
❑
❑
❑
❑
A
Symbol or code used on the plans (when plans are required) and other documents.
B
A description of the sign, or location of sign on the building; and the location of sign on construction documents.
C
OPTIONAL - Check this box only if this sign has a permanent, pre-printed, factory -installed, ENERGY VERIFIED label, confirming that the
sign complies with the Section 140.8 of the California 2013 Title 24, Part 6 Standards, using the Maximum Allowed Lighting Power
method of compliance. The only labels that will be recognized for this purpose are ENERGY VERIFIED Certification Marks authorized by
Underwriters Laboratories (UL) or other Product Certification Body accredited to ISO/IEC Guide 65 by the American National Standards
Institute in accordance with ISO/IEC 17011. Surveillance by the Accredited Certification Body shall be an ongoing annual inspection
program carried out by a Type A Inspection body in accordance with ISO/IEC 17020. For signs with such an ENERGY VERIFIED label,
columns 'D' through 'I' are not required to be filled out. Note: Using an ENERGY VERIFIED label is an optional method to validate
compliance. An ENERGY VERIFIED label is not needed for compliance.
D
The sign area in square feet.
E
List "I" if the sign is internally illuminated. List "E" if the sign is externally illuminated.
F
Allowed watts per square foot. Enter 12 if the sign is listed as "I" in column E. Enter 2.3 if sign is listed as "E" in column E.
G
Multiply the square footage in column D times the allowed Lighting Power Density (LPD = watts) in column F.
H
Show the total installed watts in the sign, as determined according to the applicable provisions of §130(c).
I
Enter Y if the number in column H is less than or equal to the number in column G. Otherwise, the sign does not comply.
1
This page doubles as a field inspection checklist.
Field Inspector Notes:
CA Building Energy Efficiency Standards - 2013 Nonresidential Compliance June 2014
sjATE OF CALIFORNIA
SIGN LIGHTING
F-173
CEC-NRCC-LTS-01-E(Revised 06/14) CALIFORNIA ENERGY COMMISSION
CERTIFICATE OF COMPLIANCE NRCC-LTS-01-E
Sign Lighting (Page 4 of 5)
Project Name: ".K%0
SfU Date Prepared: 101 tei lL
3. Specific Lighting Source Method of Compliance
Certificate of Compliance and Field Inspection Energy Checklist
Complete this part if there are signs using the Specific lighting source method of compliance. (Complete part 2 of this Certificate
of Compliance if there are signs using the maximum allowed lighting power method of compliance)
A
B
C
D
E
OPTIONAL
Specific light source used for
Field Inspector
Symbol
ENERGY VERIFIED
compliance
Check that Sign
or
Description
label
Shall include only lighting
Complies
Code
(see instructions
technologies listed below
below)
List all that apply
PAS � C3i.� t -
❑
�E �
❑
V r WP4 01a(4 la k t ca��l
❑
���
❑
-
❑
L-F_D
❑
❑
❑
A
Symbol or code used on the plans (when plans are required) and other documents.
B
A narrative description of the sign, or location of sign on the building; and the location of sign on construction documents
C
OPTIONAL - Check this box only if this sign has a permanent, pre-printed, factory -installed ENERGY VERIFIED label, confirming that this sign
complies with the Section 140.8 of the California 2013 Title 24, Part 6 Standards, using the Specific Lighting Source Method of Compliance. The
only labels that will be recognized for this purpose are ENERGY VERIFIED Certification Marks authorized by Underwriters Laboratories (UL) or
other Product Certification Body accredited to ISO/IEC Guide 65 by the American National Standards Institute in accordance with ISO/IEC
17011. Surveillance by the Accredited Certification Body shall be an ongoing annual inspection program carried out by a Type A Inspection body
in accordance with ISO/IEC 17020. For signs with such an ENERGY VERIFIED label, column 'D' is not required to be filled out. Note: Using an
ENERGY VERIFIED label is an optional method to validate compliance. An ENERGY VERIFIED label is not needed for compliance.
Specific Light Source Compliance Method. The sign(s) identified above use only the following lighting technologies:
List all applicable numbers (1 through 9) that apply in column D above for each row.
1
High pressure sodium lamps
Metal halide lamps that are pulse start or ceramic served by a ballast that has a minimum efficiency of 88 percent or
2
greater. Ballast efficiency is the measured output wattage to the lamp divided by the measured operating input wattage
when tested according to ANSI C82.6-2005.
Metal halide lamps that are pulse start that are 320 watts or smaller, are not 250 watt or 175 watt lamps, and are served by
a ballast that has a minimum efficiency of 80 percent.
3
Ballast efficiency is the measured output wattage to the lamp divided by the measured operating input wattage when tested
according to ANSI C82.6-2005.
Neon or cold cathode lamps with transformer or power supply efficiency greater than or equal to a minimum efficiency of 75 percent
D
4
when the transformer or power supply rated output current is less than 50 mA. The ratio of the output wattage to the input wattage is at
100 percent tubing load.
Neon or cold cathode lamps with transformer or power supply efficiency greater than or equal to a minimum efficiency of 68 percent
5
when the transformer or power supply rated output current is 50 mA or greater. The ratio of the output wattage to the input wattage is at
100 percent tubing load.
6
Fluorescent lighting systems meeting one of the following requirements: A. Use only lamps with a minimum color rendering index (CRI) of
80; or B. Use only electronic ballasts with a fundamental output frequency not less than 20 kHz.
7
Light emitting diodes (LEDs) with a power supply having an efficiency of 80 percent or greater;
Single voltage external power supplies that are designed to convert 120 volt AC input into lower voltage DC or AC output, and have a
8
nameplate output power less than or equal to 250 watts, shall comply with the applicable requirements of the Appliance Efficiency
Regulations (Title 20).
9
Compact fluorescent lamps that do not contain a medium screw base sockets (E24/E26).
E
This page doubles as a field inspection checklist.
Field Inspector Notes:
CA Building Energy Efficiency Standards - 2013 Nonresidential Compliance June 2014
ITATE OF CALIFORNIA
SIGN LIGHTING
CEC-NRCC-LTS-01-E(Revised 06114) GALIFURNIA ENERGY GUMMISSIUN
CERTIFICATE OF COMPLIANCE NRCC-LTS-01-E
Sign Lighting (Page 5 of 5)
Project Name: Date Prepared: •`"
v •IS
DOCUMENTATION AUTHOR'S DECLARATION STATEMENT
• 1 certify that this Certificate of Compliance documentation is accurate and complete.
Documentation Author Name:
Documentation Author Signature:
Company: C--V--1Pop-9-1 S (�A
ATE 51�►J
Signature Date: 10 IC (�
Address: �A
2AWA- VL !AT/�
CEA/ HERS Certification Identification (if applicable):
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City/State/Zip: SAMA C/Lv�R--A 4-A q5 j, U -
f
Phone: 4Le` 2-6t2,-w-
,_va
b6ttn�w-
RESPONSIBLE PERSON'S DECLARATION STATEMENT
I certify the following under penalty of perjury, under the laws of the State of California:
1. The information provided on this Certificate of Compliance is true and correct.
2. 1 am eligible under Division 3 of the Business and Professions Code to accept responsibility for the building design or system design
identified on this Certificate of Compliance (responsible designer).
3. The energy features and performance specifications, materials, components, and manufactured devices for the building design or system
design identified on this Certificate of Compliance conform to the requirements of Title 24, Part 1 and Part 6 of the California Code of
Regulations.
4. The building design features or system design features identified on this Certificate of Compliance are consistent with the information
provided on other applicable compliance documents, worksheets, calculations, plans and specifications submitted to the enforcement
agency for approval with this building permit application.
5. 1 will ensure that a completed signed copy of this Certificate of Compliance shall be made available with the building permit(s) issued for the
building, and made available to the enforcement agency for all applicable inspections. I understand that a completed signed copy of this
Certificate of Compliance is required to be included with the documentation the builder provides to a RiLdinaowner at occupancy.
Responsible Designer Name:
Responsible Designer Signature:
Company:
CO V-90 �'t� Sk 4,a SN t -A s
Date Signed:
io Is
Address: n
License:
City/State/Zip: SMTN W K Q , CA G15OS u
Phone: 4.
CA Building Energy Efficiency Standards - 2013 Nonresidential Compliance June 2014