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13-1685 (RC)' P.O. BQX 1504 VOICE (760) 777-7012 78-495 CALLE TAMPICO FAX (760) 777-7011 - L,A QUINTA, CALIFORNIA 92253 BUILDING & SAFETY DEPARTMENT INSPECTIONS (760) 777-7153 BUILDING PERMIT . Application Number: 13-00001685 Property Address: 78965 HIGHWAY 111 STE 100 APN: 643-020-056- 7 - Application description: REMODEL - COMMERCIAL Property Zoning: REGIONAL COMMERCIAL Application valuation: 585000 Applicant: Architect or'Engineer: ------------------ LICENSED CONTRACTOR'S DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professionals Code, and my License is in full force and effect. License Class: B License No.: 194614 Date: Contractor• OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury that I am exempt from the Contractor's State License Law for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county that requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractor's State License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred_ dollars ($500).: (_ 1 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 and Professions Code: The Contractors' State License Law does not apply to an owner of property who builds or improves thereon, and who does the work himself or herself through his or her own employees, provided that the improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for the purpose of sale.). (_ 1 I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of property who builds or improves thereon, and who contracts for the projects with a contractor(s) licensed pursuant to the Contractors' State License Law.). (_) I am exempt under Sec. , B.&P.C. for this reason Date: Owner: CONSTRUCTION LENDING AGENCY I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Lender's Name: _ Lender's Address: LQPERMIT Date: 3/28/14 Owner: WASHINGTON 111 LTD 80618 DECLARATION AVENUE " INDIO, CA 92201 Rt Contractor:ERDMAN COMPANY 2014 1 ERDMAN PLACE MADISON, WI 53717 61TYQFLAgUINTA (608)410-8000 FINANCE DEPT Lic. No.: 194614 �m— WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided Z by Section 3700 of the Labor Code, for the performance of the work for which this permit ised.and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy number are: Carrier THE HARTFORD Policy Number 41WNQUI190 _ 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 workers' compensation laws of California, and agree that, if I should bec a subject to the workers' compensation provisions of Section 3700 of the Labor Co shal orthwith comply with those provisions. ' Kate: 3 '��'/% Applicant: r' WARNING: FAILURE TO SE URE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.. APPLICANT ACKNOWLEDGEMENT IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the conditions and restrictions set forth on this. application. 1. Each person upon whose behalf this application is made, each person at whose request and for whose benefit work is performed under or pursuant to any permit issued as a result of this application, the owner, and the applicant, each agrees to, and shall defend, indemnify and hold harmless the City of La Quinta, its officers, agents and employees for any act or omission related to the work being performed under or following issuance of this permit. 2. Any permit issued as a result of this application becomes null and void if work is not commenced within 180 days from date of issuance of such permit, or cessation of work for 180 days will subject permit to cancellation. 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 county to enter upon the above-mentioned propent spins fiction purposes. KPate: 3�& °/ Signature (Applicant or Agent)' LQPERMIT • Application Number . . . . 13-00001685 r ------ Structure Information 2,969SF TI/VB/B-OCC/30-OL/SPRINKLED ----- Other struct info CODE EDITION 2010 FIRE SPRINKLERS FULLY MIXED-USE OCCUPANCY B OCCUPANT LOAD 30.00 , ---------------------------------------------------------------------------- 1ST FLOOR SQUARE FOOTAGE 2969.00 Permit . . . REMODEL 2013 Additional desc . ' Permit Fee . . . . 155.87 Plan Check Fee ., .00 Issue Date . . . . Valuation . . . . 0 Expiration Date . 9/24/14 Qty Unit Charge Per Extension . 1.00 48.6200 LS MISC REMODEL, 1ST 100 SF 48..62 5.00 21.4500 ---------------------------------------------------------------------------- EA MISC REMODEL, ADDL 500 SF 107.25 Permit . . . PLUMBING 2013 Additional desc . . Permit Fee . . . . 166.88 Plan Check Fee .00 Issue Date . . . . Valuation . . . . 0 Expiration Date, 9/24/14 Qty Unit Charge Per Extension 12.00 11.9200 EA PLBG FIXTURE/TRAP 143.04 1.00 11.9200 EA PLBG WATER HEATER/VENT 11.92 1.00 11.9200 ---------------------------------------------------------------------------- EA PLBG WATER INST/ALT/REP 11.92 Permit . . . MECHANICAL 2013 Additional desc . Permit Fee . . . . 35.76 Plan Check Fee .00 Issue Date . . . . Valuation . . . . 0 Expiration Date . . 9/24/14 Qty Unit Charge Per Extension 2.00 1.1.9200 EA MECH APPL REP/ALT 23.84 1.00 11.9200 ---------------------------------------------------------------------------- EA MECH VENT FAN 11.92 Permit . . . ELECTRICAL 2013 Additional desc . Permit Fee . . . . 143.00 Plan Check Fee .00 Issue Date . . . . Valuation . . . . 0 Expiration Date . . 9/24/14 LQPERMIT LQPERMIT Application Number -13-00001685 Permit . . . . ELECTRICAL 2013 Qty Unit Charge Per Extension - 1.00 107.2500 LS ELEC NEW COMM, FIRST 2 KSF 107.25 1.00 35.7500 EA ELEC NEW COMM, ADD -L 2 KSF 35.75 Special Notes and Comments 2,969SF TI/VB/B70CC/30-OL/SPRINKLED [URGENT CARE CENTER] INCLUDES CREATION OF ADDITIONAL BUILDING SUITE - SEPARATE PERMIT REQUIRED FOR OCCUPANCY. THIS PERMIT DOES NOT INCLUDE ALTERATION TO THE EXTERIOR OF THE BUILDING OR SIGNAGE. 2010 CALIFORNIA BUILDING CODES. March 25, 2014 4:23:52 PM AORTEGA Other Fees . . ART IN PUBLIC PLACES -COM 2925.00 BLDG STDS ADMIN (SB1473) 24.00 PLAN CHECK, ELECTRICAL 92:47 PLAN CHECK, REMODEL 218.79 PLAN CHECK, MECHANICAL 14.31 PLAN CHECK, PLUMBING 162.11 STRONG MOTION (SMI) - COM 122.85 Fee summary Charged Paid ------------------------------------- Credited -------------------- Due Permit Fee Total .501.51 .00. .00 -501.51 Plan Check Total .00 .00 .00 .00 Other Fee Total 3559.53 .00 .00 3559.53 Grand Total 4061.04 .00 .00 4061.04 "FC&liFO Bin (AR City of La Quinta oEe Building &r Safety Division C1 ? -Y - 4 2013 P.O. Box 1504, 78-495 Calle Tampico COMM of t La Quinta, CA 92253 - (760) 777-7012 �Nj�Y pE Q(1j1VT Building Permit Application and Tracking Sheet QPM Permit # ��•lV 'Project Address v -96S I_ 11)� Owner's Name:k) ,) ,, Ci4✓� /p��,✓ S A. P. Number: Address:i - /� to .56AJ, )/ I Legal Description: City, ST, Zip: 4+.- Qttit j 4-6 Contractor: Crdmj►'\� [ 1 _.=s - Telephone: So D 3 d - _ 1 ) :< ?::>:>'# F > i<>:k>::?< ,; :;::; > :> Address: 0 N to C o,,4 , -n a.) I l4} - Q ~ ' Pro'ect Descri tion ` i P �T� 5. ro `Q i cogs, sfs City,ST,Zip: `%jV4,\,u N WT 5371% _ Telephone:(,6 8 to 8 ocv y 4Lic..M..:,: F. f— D � ft�r w State_-L--ic. # City Arch., Engr., Designer: _' N l- l l P2sl �: 1 I �► 1 Address: Cr iV 0 $, K o: i Trori S /- � C � t✓ � � h� City., ST, Zip: r Telephone: :.::.,.;.:::;>;:;;f:;;:.;;:<:::;:`:`:<.';::""': `��><<�:::... .;.;.;•r:;.•x,;:;�;::::•::»::.>::;:<:>Cons ri<.;>:.»::><;:.::::::;s;::::>,::s>;<.•;:<:»>:.:;: 4;s:;;;:':s;s:;:>::?<:e:;,. truction TYPe: Occupancy: State Lic. #: Project type (circle one): New Add'n Alter Repair Demo t _Name of Contact Person;_ d bbl 5 Sq. Ft.: #Stories: #Units: Telephone# -of -Contact Person: 3 54f 6 j i( EstimatedValue-of-P-roject: S S o APPLICANT: DO NOT WRITE BELOW THIS LINE # Submittal Req'd Rec'd TRACKING PERMIT FEES Plan Sets Plan Check submitted`[us,Item Amount Structural Calcs. Reviewed, ready for corrections Plan Check Deposit Truss Calcs. Called Contact Person Plan Check Balance Title 24 Cales. Plans picked uz�.a—� 5" 5 1 Construction Flood plain plan Plans resubmitted Z Mechanical Grading plan 2.4 Review, ready for correction ssue lectrical Subcontactor List Called Contact Person Plumbing Grant Deed Plans picked up A S.M.I. H.O.A. Approval Plans resubmitted Grading IN HOUSE:- M Reyiew, ready for correctionsrissue Developer Impact Fee Planning Approval Called Contact Person A.I.P.P. Pub. Wks. Appr Date of permit issue School Fees Total Permit Fees 1 Z 9otg — SAW -Art" ?. U13 SeWT To 65C.1L. C&,&%f4" j& C - 0A I Tdy � t <:. COMMUNITY DEVELOPMENT DEPARTMENT a 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 (760) 777-7125 FAX (760) 777-7011 To: Greg Butler, Building Official From: Les Johnson, CDD Director Permit #: 13-1685 Building Plans Approval (This is an approval to issue a Building Permit) To PD: March 25, 2014 Due Date: Status: 1 st Planning has reviewed the Building Plans for the following project: Description: Urgent Care Center Tenant Imrpvoement Address or General Location: 78-965 Highway 111 (Previous ReMax Office) Applicant Contact: Joel Santos (603) 548-6500 Planning finds that: ❑ ...these Building Plans do not require Planning approval. ...these Building Plans are approved by Planning. ❑ ...these Building Plans require corrections. Please forward a copy of the attached corrections to the applicant. When the corrections are made please return them to Planning for review. I Les Johnson, Community Development Department Director Date PROUDLY SERVING THE UNINCORPORATED AREAS OF RIVERSIDE COUNTY AND THE CITIES OF: BANNING BEAUMONT CALIMESA " CANYON LAKE COACHELLA DESERT HOT SPRINGS E4SfVALE INDIAN WELLS INDIO JURUPA VALLEY LAKE ELSINORE LA QUINTA MENIFEE MORENO VALLEY NORCO PALM DESERT PERRIS RANCHO MIRAGE RUBIDOUx CSD SAN JACINTO TEMECULA WILDOMAR 0 BOARD OF SUPERVISORS: KEVIN JEFFRIES DISTRICT 1 JOHN TAVAGLIONE DISTRICT 2 JEFF STONE DISTRICT 3 JOHN BENOIT DISTRICT 4 MARION ASHLEY DISTRICT 5 RIVERSIDE COUNTY FIRE DEPARTMENT IN COOPERATION WITH THE CALIFORNIA DEPARTMENT OF FORESTRY AND FIRE PROTECTION 77-933 Las Montanas Rd., Ste. #201, Palm Desert, CA 92211-4131 • Phone (760) 863-8886 • Fax (760) 863-7072 www.rvcfiire.org March 28, 2014 RE: TENANT IMPROVEMENT PLAN CHECK -Non Structural LAQ- I 4 -TI -008 Urgent Care Center 78-965 Hwy 111 La Quinta, CA You have been issued a release for a tenant improvement on an existing building. THIS IS NOT AN OCCUPANCY PERMIT. It is prohibited to use/process or store any materials in this occupancy that would classify it as an "H" occupancy per Sec. 307 of the 2013 CBC. THE FOLLOWING CONDITIONS MUST BE MET PRIOR TO INSPECTION: Install door hardware and exit signs as per Chapter 10 of the CBC. A minimum 2AlOBC Fire Extinguisher, (State Fire Marshal Approved) must be mounted in a visible location within 75' walking distance from any point in your building or suite. Fire extinguishers can be installed by a licensed extinguisher company with a State Fire Marshal service tag attached to the extinguisher, or purchased from a retail store with a sales receipt attached. A licensed fire extinguisher company must service extinguisher yearly. All breakers must be labeled and a clearance of 36 inches must be maintained around the panel at all times: A durable sign stating "This door to remain unlocked during business hours" shall be placed on.or adjacent to the front exit door. The sign shall be in letters not less than one inch high on a contrasting background. An approved audible interior notification alarm device shall be provided in approved location. A C-10 licensed contractor must submit plans, designed in accordance with NFPA 72 to the Fire Department for review and approval prior to installation Approved suite addresses shall be placed in such a position to be plainly visible and legible from the street. Said numbers shall contrast with their background. Provide key(s) to the tenant space for inclusion in the main building Knox Box. Key(s) shall have durable and legible tags affixed for identification. Key(s) shall be provided at time of final inspection. A five year fire sprinkler service and certification for the existing fire sprinkler system is required per Title 19. A licensed C-16 contractor must complete the servicing and certification. The maintenance records for the fire sprinkler system must be available on-site for review. Applicable room door(s) shall be posted "ELECTRICAL ", "FACP", "FIRE RISER" and "ROOF ACCESS" on the outside of the door so it is visible and in a contracting color. As it may be necessary to maintain proper fire sprinkler protection due to constructions changes, fire sprinkler system plans for the tenant improvement area may be required to be submitted to the Fire Department for review. NOTE: Review of this plan does not include medical gas systems. Nothing in our review shall be construed as encompassing structural integrity. Review of this plan does not authorize or approve any omission or deviation from all applicable regulations. Final approval is subject to field inspection. Applicant/installer shall be responsible to contact the Fire Department to schedule inspections. A re -inspection fee will be required if more than one (1) inspection is necessary. Requests for inspections are to be made at least 72 hours in advance and may be arranged by calling (760) 863 8886. All questions regarding the meaning of these conditions should be referred to the Fire Department Planning & Engineering Staff at (760) 863 8886. Sincerely, By: ja. 5,; Jason Stubble Fire Safety Specialist EsGil Corporation In Partnership with Government for Buifding Safety DATE: 03/17/2014 ❑ A PLICANT JURIS. JURISDICTION: La Quinta ❑ PLAN REVIEWER ❑ FILE PLAN CHECK NO.: 13-1685 SET: II PROJECT ADDRESS: 78-965 Hwy. 111 PROJECT NAME: Urgent Care Center ®" The plans transmitted herewith have been corrected where necessary and substantially comply with the jurisdiction's building codes: ❑ The plans transmitted herewith will substantially comply with the jurisdiction's codes when minor deficiencies identified below are resolved and checked by building department staff. ❑ The plans transmitted herewith have significant deficiencies identified on the enclosed check list and should be corrected and resubmitted for a complete recheck. ❑ The check list transmitted herewith is for your information. The plans are being held at Esgil Corporation until corrected plans are submitted for recheck. ❑ The applicant's copy of the check list is enclosed for the jurisdiction to forward to the applicant contact person. ❑ The applicant's copy of the check list has been sent to: ® EsGil Corporation staff did not advise the applicant that the plan check has been completed. ❑ EsGil Corporation staff did advise the applicant that the plan check has been completed. Person contacted: Date contacted: (by:' ) Mail .Telephone Fax In Person ❑ REMARKS: By: John Le Vey EsGil Corporation ❑GA ❑EJ ❑MB ❑PC Email: Enclosures: 03/10/2014 Telephone #: Fax #: 9320 Chesapeake Drive, Suite 208 ♦ San Diego, California 92123 ♦ (858) 560-1468 ♦ Fax(858)560-1576 O JFa1L3d ANSI- O'r AW 395 3LVU*:M J>D Orr, / 'O A ~ o• .. Q O A ' y m / O O CL 3 a+ 10 XO / 11ti1t � O H � O .dam" a* A M L't A d es t A toJ� mro o .moi --Aq Pa*mD _._ Ag umma 1!a!gx] +poor '9 l.wdyalgia ja9u^N BwAma io•Qzireieo pafoad m ? v, LN. 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BIW Aq UMvQ 8 MIPS"8 *A mPuq t1dZOF ofzw4m[I9m auaa I!q!gx3 Booz .9 I.Udy MR0 o �9W^N lo•Qi7relEo »ajad � x�tU.xatt[ •��:�•a+a •«a'!h,.e„ so«6Ya'euapasad Na01 •!.v&7 O.O w017Rrtda� 'P=1 ![! .4 lVl is X -*P "y �ap,,.a aoe C �0 V a o"O wrewa y Fartdnwa 4 vP.rnJ�go Q PMM" I 41��H 3ilil Mi 1N3W 013/00 KUNnwwCD j` a _ '�► • O Cww -a tiIOZ 9 833(13A / l Rd .. p21 - a � Q ieaW=a ieewaa wa aus atvax� �, � '' irsaao�naa �ivaa-� �aaa 3anu►a �.�� ...—..� , Wolof•l•� � rt c flif, '�`-mooL6. a o a CL. /oo CL. 1TM SR.7lGe/J3M � .tO�DW-L�fk•' • � _ � — -� � 'i � . . CEJ— Com— �— sCA +� s L7 � o �� 4 ,,,•t, I�tt� =.t ;t �• • / S 0 c ✓ IIt JIifMH4IH a • , , s � •ow � 1Vb -ted : N� N i ✓ o m >7res�sr� o= d M to ro to F: o - a. isas IM41d pas-vaij - 1-71-D 0 C 7n4A CERTIFICATE OF COMPLIANCE (Page l of 4) LTG -1C - Project Name: National Urgent Care Hold %9Mhw1wrqluyaclgwal�nter Date: November% 2013 Project Address: 78-965 HWY. 111, La Quinta, CA 92253 Climate Zone: Building CFA :2857 Unconditioned Floor Area: General Information Building Type: 0 Nonresidential ® High -Rise Residential ® Hotel/Motel ®SchoolsRelocatable Public ® Schools ® Conditioned Spaces ® Unconditioned Spaces Phase of Construction: ® New Construction ® Addition ®x Alteration Method of Compliance: 0 Complete Building ® Area Category 13 Tailored Documentation Author's Declaration Statement • I certify that this Certificate of Compliance documentation is accurate and complete. Name: Randy Wilde Signature: Company: Erdman Company Date November 9, 2013 Address: One Erdman Place If applicable: CEA# CEPE # City/State/ZipMadison, WI 53717 Phone: 608-410-8000 Principal Lighting Designer's Declaration Statement • 1 am eligible under Division 3 of the California Business and Professions Code to accept responsibility for the lighting design. • This Certificate of Compliance identifies the lighting features and performance specifications required for compliance Nvith Title 24, Pages I and 6 of the California Code of Regulations. • The design features represented on this Certificate of Compliance are consistent with the information provided to document this design on the other applicable compliance forms, worksheets, calculations, plans and specifications submitted to the enforcement agency for approval with this building permit application. Name: Mark Hoskins Signatu Company: Company Phone Phone:608-410-8000 Address: One Erdman Place License#E 15664 city/State/Zip:Madison, WI 53717 Date: November 9, 2013 Lighting Mandatory Measures E101 Indicate location on building plans of Mandatory Measures Note Block: LIGHTING COMPLIANCE FORMS & WORKSHEETS (check box if worksheet is included) For detailed instructions on the use of this and all Energy Efficiency Standards compliance forms, please refer esident' published b the California Energy Commission. IN LTG -1C Pages 1 through 4 Certificate of Compliance. All Pages required on Ian I ® LTG -2C Lighting Controls Credit Worksheet BUILDING & SAFE77 DEPT. ®x LTG -3C Indoor Lighting Power Allowance ® LTG -4C Pages 1 through 4 Tailored Method Worksheet ® LTG -5C Pages I and 2 Line Voltage Track Lighting Worksheet LOATE -1 11014— BY—,a_ I Nonresidential Compliance'Fortns Julv 2010 CERTIFICATE OF COMPLIANCE (Page 2 of 4) LTG-1C INDOOR LIGHTING SCHEDULE and FIELD INSPECTION ENERGY CHECKLIST Project Name: National Urgent Care Holdings, Inc. Urgent Care Center Date: November 9, 2013 Installation Certificate, LTG-I-INST (Retain a copy and verify form is completed and signed.) ® Field Inspector Certificates of Acceptance, LTG-2A and LTG-3A (Retain a copy and verify form is completed and signed.) ® Field Inspector A separate Lighting Schedule Must Be Filled Outfor Conditioned and Unconditioned Spaces Installed Lighting Power listed on this Lighting Schedule is only for: IM CONDITIONED SPACE ® UNCONDITIONED SPACE M The actual indoor lighting power listed below includes all installed permanent and portable lighting systems in accordance with §146(a ® Only for offices: Up to the first 0.2 ivatts per square foot of portable lighting shall not be required to be included in the calculation of actual indoor lighting power density in accordance with the Exception to §146(a). All portable lighting in excess of 0.2 watts per s care foot is totaled below. Luminaire Schedule (Type, Lamps, Ballasts Installed Watts A B C D E F G H 0 C3 Complete Luminaire Description E(i.e, 3 lamp fluorescent troffer,ca z — F32T8, one dimmable electronic ballast How wattage was Field determined Ins ector2 _ w .CEC According ° ¢ = Default to from § 130 8 3 NA8 d ore ° ° c 3 a w 3A 3 lamp fluorescent troffer, F32T8, one electronic ballast 72 ® ®x 1 72 13 2A 2 lamp fluorescent troffer, F32T8, one electronic ballast 48 Ex 21 1008 26 2 lamp fluorescent troffer, F32T8, one electronic ballast 48 ® ®x 5 240 2Cm 2 lamp fluor troffer, tandem - master, F32T8, one electronic ballast 95 [3 1 x . 6 570 2Cs 2 lamp fluor troffer, tandem - satellite, F32T8, no ballast 0 ri 1 17 6 0 6F 1 lamp c.f. can light, 26TRT, one electronic ballast 28 0 x 1 28 6A 1 lamp incandescent can light, 75W Al 75 Mx 8 600 13 1 rl 13 13 E EXIT LED exit sign 1 16 6 913 1 lamp LED pendant 10 0 x 13 30 - B— - cur- 2E 2-lamp fluorescent troffer, F32T8, one electronic ballast 48 0x 4 192 2F 2-lamp fluorescent troffer, F32T8, one electronic ballast 48 x 2 96 13 1:3 13 13 8P 1-1amp fluorescent under cabinet light, one electronic ballast 24 x 2 48 6J 1 lamp c.f. can light, 42TRT, one electronic ballast 45 x 1 45 n 13 INSTALLED WATTS PAGE TOTAL: 2935 1 Installed Watts Building Total 2935 Building total number of pages (Sum of all pages) Enter into LTG-IC Page 4 of 4 1. Wattage shall be determined according to Section 130(d and e). Wattage shall be rating of light fixture, not rating of bulb. 2. 1f Fail then describe on Page 2 of the Inspection Checklist Form and take appropriate action to correct. Veri,fybuildingplans if necessar . 2008 Nonresidential Compliance Forms July 2010 CERTIFICATE OF COMPLIANCE (Page 3 of 4) LTG -IC Project Name: Date: National Urgent Care Holdings, Inc. Urgent Care Center November 9, 2013 INDOOR LIGHTING SCHEDULE and FIELD INSPECTION ENERGY CHECKLIST Fill in controls for all spaces: a) area controls, b) multi-level controls, c) manual daylighting controls for daylit areas > 250f?, automatic daylighting controls for daylit areas > 2,500 ft1, d) shut-off controls, e) display lighting controls, )9 tailored lighting controls - general lighting controlled separately from display, ornamental and display case lighting and demand responsive automatic controls for retail stores > 50,000 ftp, in accordance with Section 131. MANDATORY LIGHTING CONTROLS - FIELD INSPECTION ENERGY CHECKLIST Field Inspector Type / Description Number of Units Location in Building Pass Fail area controls - wall mounted occupancy sensors (OS, OS3) 12 exams, office, lab, receptionist, toilets 13 13 area controls - wall mounted timer switch (T) 2 storage ® a area controls - ceiling mounted occupancy sensor (C2) 6 circulation hallways, x-ray, waiting 13 13 area controls - wall mounted dual channel occ. sensor (OS2) 3 large exams, lounge o13 0 13 M 13 13 0 13 13 13 13 13 13 11 13 13 0 13 13 Field Inspector's Notes or Discrepancies: 2008 Nonresidential Compliance Forms July 2010 CERTIFICATE OF COMPLIANCE (Page 4 of 4) LTG -1C Project Name: National Urgent Care Holdings, Inc. Urgent Care Center Date: November 9, 2013 Conditioned and Unconditioned space Lighting must not be combined for compliance Indoor Lighting Power for Conditioned Spaces indoor Lighting Power for Unconditioned Spaces Installed Lighting from Conditioned LTG -1C Page 2 Watts installed Lighting from Unconditioned LTG -1 C Page 2 Watts 2935 JJ Lighting Control Credit.- Conditioned Spaces from LTG -2C O Lighting Control Credit Unconditioned Spaces from LTG -2C - Adjusted Installed Lighting Power — 2935 •! J Adjusted Installed Lighting Power — Complies if Installed:5 Allowed = Complies if Installed:5 Allowed 2 Allowed Lighting Power3143 Conditioned S aces (from LTG -3C) Allowed Lighting Power Unconditioned Spaces (from LTG -3C) Required Acceptance Tests Designer: This form is to be used by the designer and attached to the plans. Listed beloiv is the acceptance test for the Lighting system, LTG -2A and LTG -3A. The designer is required to check the acceptance tests and list all control devices serving the building or space shall be certified as meeting the Acceptance Requirementsfor Code Compliance. If all the lighting system or control of a certain type requires a test, list the different lighting and the number of systems. The iVA7 Section in the Appendix of the Nonresidential Reference Appendices Manual describes the test. Since this form will be part of the plans, completion of this section tivill alloiv the responsible party to budget for the scope of ivo•k appropriately. Forms can be grouped by type of Luminaire controlled. Enforcement Agency: Systems Acceptance. Before Occupancy Permit is granted for a newly constructed building or space or when ever new lighting system with controls is installed in the building or space shall be certified as meeting the Acceptance Requirements. The L TG -2A and L TG -3A forms are not considered a complete form and are not to be accepted by the enforcement agency unless the boxes are checked and/or filled and signed. In addition, a Certificate of Acceptance forms shall be submitted to the enforcement agency that certifies plans, specifications, installation certificates, and operating and maintenance information meet the requirements of§10-103(b) of Title 24 Part 6. The field inspector inust receive the properly filled out and signed forms before the building can receive final occupancy. A copy of the LTC -2A and LTG -3A for each di fferent lighting luminaire controls must be provided to the oivner of the buildingfor their records. Luminaires Controlled LTC -2A and 3A Equipment Re uirin Testing i a ar Description Z o U Location Controls and Sensors and Automatic Daylighting Controls Acceptance Occupany sensors wall and ceiling mounted sea 21 exams, office, lounge, hallwqU Im Electronic timer switches wall mounted timer switches 2 storage 19 13 13 13 13 13 13 2008 Nonresidential Compliance Forms July 2010 CERTIFICATE OF ACCEPTANCE LTG -2A Lighting Control Acceptance Document (Pa e 1 of 3) Project Name/Address: National Urgent Care Holdings, Inc. Urgent Care Center 78-965 HWY 111, La Quinta, CA 92253 System Name or Identification/Tag: Occupancy Sensors System Location or Area Served: Throughout Infill Space Enforcement Agency: Permit Number: Note: Submit one Certificate of Acceptance for each system that must demonstrate compliance. Enforcement Agency Use: Checked by/Date FIELD TECHNICIAN'S DECLARATION STATEMENT • I certify under penalty of perjury, under the laws of the State of California, the information provided on this form is true and correct. • I am the person who performed the acceptance requirements verification reported on this Certificate of Acceptance (Field Technician). • 1 certify that the construction/installation identified on this form 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 • 1 have confirmed that the Installation Certificate(s) for the construction/installation identified on this form has been completed and is posted or made available with the building permit(s) issued for the building. Company Name: Field Technician's Name: Field Technician's Signature: 608-410-8000 Date Signed: Position With Company (Title): RESPONSIBLE PERSON'S DECLARATION STATEMENT • I certify under penalty of perjury, under the laws of the State of California, that 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 form. • l am a licensed contractor, architect, or engineer, who is eligible under Division 3 of the Business and Professions Code, in the applicable classification, to take responsibility for the scope of work specified on this document and attest to the declarations in this statement (responsible person). • l certify that the information provided on this form substantiates that the construction/installation identified on this form 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 • I have confirmed that the Installation Certificate(s) for the construction/installation identified on this form has been completed and is posted or made available with the building permit(s) issued for the building. • I 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. Company Name: Erdman Company Phone: 608-410-8000 Responsible Person's Name: Mark Hoskins Responsible Person's Signature: Will sign after technician completes. License:E 15664 Date Signed: Position With Company (Title): Electrical Engineering Manger Occupant Sensor, Manual Daylighting Control, and Automatic Time Switch Control Intent: I Lights are turned off when not needed per Section 1 19(d) & 131(d). Construction Inspection 1 Instrumentation to perform test includes, but not limited to: a. Hand-held amperage and voltage meter b. I Power meter continued on next page 2008 Nonresidential Acceptance Forms August 2009 CERTIFICATE OF ACCEPTANCE LTG -2A Lighting Control Acceptance Document (Page 2 of 3) Project Name/Address: National Urgent Care Holdings, Inc. Urgent Care Center 78-965 HWY 111, La Quinta, CA 92253 System Name or Identification/Tag: Occupancy Sensors System Location or Area Served: Throughout Infill Space 2 Occupancy Sensor Construction Inspection ❑ Occupancy sensor has been located to minimize false signals ❑ Light meter ❑ Ultrasonic occupancy sensors do not emit audible sound (119a) 5 feet from source 3 Manual Daylighting Controls Construction Inspection If dimming ballasts are specified for light fixtures within the daylit area, make sure they meet all the Standards ❑ requirements, including "reduced flicker operation" for manual dimming controls stems 4 Automatic Time Switch Controls Construction Inspection a. Automatic time switch control is programmed for (check all): ❑ Weekdays ❑ Weekend ❑ Holidays b. Document for the owner automatic time switch programming (check all): ❑ Weekdays settings ❑ Weekend settings ❑ Holidays settings ❑ Set-up settings ❑ Preference program setting ❑ Verify the correct time and date is properly set in the time switch ❑ Verify the battery is installed and energized ❑ Override time limit is no more than 2 hours ❑ Occupant Sensors and Automatic Time Switch Controls have been certified to the Energy Commission in accordance with the applicable provision in Section 119 of the Standards, and model numbers for all such controls are listed on the Commission database as Certified Appliance and Control Devices A. Select Acceptance Test (indicate lighting control systems Names/Designations by the applicable tests below) 1 Occupancy Sensor ❑ 2 Manual Daylighting Controls ❑ 3 Automatic Time Switch Controls B. Equipment Testing Requirements Check and verify those items applicable to selected system: Applicable Lighting Control Systems Occupancy Sensor - Step 1: Simulate an unoccupied condition 1 2 3 a' Lights controlled by occupancy sensors turn off within a maximum of 30 minutes from start of an unoccupied condition per Standard Section 119(d) Y / N Y / N Y / N b The occupant sensor does not trigger a false 'on" from movement in an area adjacent to the controlled space or from HVAC operation Y / N Y / N Y / N c. Signal sensitivity is adequate to achieve desired control Y / N Y / N Y / N Occupant Sensor - Step 2: Simulate an occupied condition a. Status indicator or annunciator operates correctly Y / N Y / N Y / N b Lights controlled by occupancy sensors turn on when Immediately upon an occupied condition OR this requirement is mutually exclusive with Step 2.c.) Y / N Y / N Y / N C. Sensor indicates space is 'occupied" and lights turn on manually Y / N Y / N Y / N continued on next page 2008 Nonresidential Acceptance Forms August 2009 CERTIFICATE OF ACCEPTANCE LTG -2A Lighting Control Acceptance Document (Page 3 of 3) Project Name/Address: National Urgent Care Holdings, Inc. Urgent Care Center 78-965 HWY 111, La Quinta, CA 92253 System Name or Identification/Tag: Occupancy Sensors System Location or Area Served: Throughout Infill Space Occupant Sensor - Step 3: System returned to initial operating conditions Y / N Y / N Y / N Occupant Sensor - Step 4 - Sensor is also a multi -Level Occupant Sensor used to qualify for a Power Adjustment Factor in Section 146(a)2D of the Standards. If yes, then `a,' `b,' and `c' must also be yes. Y / N Y / N Y / N a The first stage activates between 30 to 70% of the lighting either manually or automatically. Y / N Y / N Y / N b. A reasonably uniform level of illuminance is achieved by dimming of all lamps or luminaires; or by switching alternate lamps in luminaires, alternate luminaires, or alternate rows of luminaires. Y / N Y / N Y / N c. After the first stage occurs, manual switches have been provided to activate the alternate set of lights, activate 100% of the lighting power, and manually deactivate all of the lights. Y / N Y / N Y / N Manual Daylighting Controls - Step 1: Manual switching control a. At least 50% of lighting power.in daylit areas is separately controlled from other lights Y / N Y / N Y / N b. The amount of light delivered to the space is uniformly reduced Y / N Y / N Y / N Manual Daylighting Controls - Step. 2: System returned to initial operating conditions Y / N Y / N Y / N Automatic Time Switch Controls - Step 1: Simulate occupied condition a. All lights can be turned on and off by their respective area control switch Y / N Y / N Y / N b Verify the switch only operates lighting in the ceiling -height partitioned area in which the switch is located Y / N Y / N Y / N Automatic Time Switch Controls - Step 2: Simulate unoccupied condition a. I All non-exempt lighting turn off per Section 131(d)l Y / N Y / N Y / N b. Manual override switch allows only the lights in the selected ceiling height partitioned space where the override switch is located, to turn on or remain on until the next scheduled shut off occurs Y / N Y / N Y / N C. All non-exempt lighting turns off Y / N Y / N Y / N Automatic Time Switch Controls - Step 3: System returned to initial operating conditions Y / N Y / N Y / N Note: Shaded areas do not apply for particular test procedure C. PASS / FAIL Evaluation (check one): ❑ PASS: All applicable Construction Inspection responses are complete and all applicable Equipment Testing Requirements responses are positive (Y - yes) ❑ FAIL: Any applicable Construction Inspection responses are incomplete OR there is one or more negative (N - no) responses in any applicable Equipment Testing Requirements section. Provide explanation below. Use and attach additional pages if necessary. 2008 Nonresidential Acceptance Forms August 2009 INDOOR LIGHTING POWER ALLOWANCE LTG -3C Project Name: National Urgent Care Holdings, Inc. Urgent Care Center Date: November 9, 2013 ALLOWED LIGHTING POWER Chose One Method A Separate LTG -3C must be filled out for Conditioned and Unconditioned Spaces. Indoor Lighting Power Allowances listed on this page are only for: 0 CONDITIONED spaces ® UNCONDITIONED spaces COMPLETE BUILDING METHOD BUILDING CATEGORY (From §146 Table 146 Medical Buildinqs and Clinics REA CATEGORY METHOD — Part A A AREA CATEGORY (From $146 Table 146- WATTS COMPLETE ��ALLOWED PER (ft') X IBLDG.AREA = WATTS 1.1 1 2857 1 3143 TOTALS 1 2857 1 11 3143 AREA WATTS WATTS ALLOWED B C D PER (ftz) X AREA (ftz) = WATTS Sum of Additional Allowed Watts from Area Category Method — Part B from table below TOTALS AREA WATTS AREA CATEGORY METHOD — Part B Additional Wattage Allowance from Table 146-F Footnotes A B C D E F G Primary Function S Ft Additional Watts Per ftz Allowed Wattage Allowance (B x C Description(s) and Quantity of Special Luminaire z Types in each Primary Function Area Total Design Watts ALLOWED WATTS Smaller of D or F TOTALS — Enter into Area Category Method — Part A (table above) ' Additional watts available only when allowed according to the footnotes on bottom of Table 146-F for chandelier or sconce; art, craft, assembly or manufacturing specialized task work; precision commercial/ industrial work; or lab specialized task work. z. Special luminaires are light fixtures described in the Table 146-F Footnotes that are subject to an additional wattage allowance. TAILORED METHOD Total Allowed Watts using the Tailored Method taken from LTG -4C (Page 1 of 4) Row 3 The indoor lighting power allowance using the Tailored Method of compliance shall be determined using the LTG -4C set of forms. A separate set of LTG -4C forms shall be filled out for CONDITIONED and UNCONDITIONED spaces 2008 Nonresidential Compliance Forms August 2009