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DocuSign Envelope I D: 7BC41 E96-41 BB-4258-90E9-667EF054EEB7
CITY OF NEWPORT BEACH
xg San ®ollar G4
Community Development Department I Building Division
100 Civic Center Dr. 1 P.O. Box 1768 1 Newport Beach, CA 92658
www.newportbeachca.aov 1(949)644-3200
CALGREEN DOCUMENTATION GOMPLIANCE CERTIFICATION
1221 W. coast Highway, Newport Beach, cA 92663 x2019-0162
ADDRESS: PERMIT NO.:
THIS FORM SHALL BE COMPLETED AND SIGNED PRIOR TO REQUEST FOR FINAL BUILDING
INSPECTION. ONE COPY OF THIS FORM SHALL BE SUBMITTED TO THE BUILDING INSPECTOR AT
FINAL INSPECTION AND ONE SHALL BE PROVIDED TO THE BUILDING OWNER AS PART OF THE CAL
GREEN CERTIFICATION PACKAGE.
The following section shall be completed by a person with overall responsibility for the planning and
design portion of the project.
REQUIRED DOCUMENTATIONS PROVIDED TO THE PROPERTY OWNER(S)
® Franchise Hauler for Construction/Demolition Waste (65% min. reuse of nonhazardous waste)
19 VOC Contents Limitation
q Formaldehyde Emissions Limitation
❑ T-24 Energy Certificate of Installations (Env., QII, Lighting, Photovoltaic, Mech., Plumb.)
❑ T-24 Energy Certificate of Verifications or Acceptance( Env., QII, Lighting, Photovoltaic, Mach.,
Plumb., HERS)
Ek Operations and Maintenance Manual
MOISTURE CONTENT OF BUILDING MATERIAL (RESIDENTIAL CONSTRUCTION ONLY)
® I certify that the moisture content of the wall and floor framing is less than 19 percent as
determined in accordance with Section 4.505.3 of CAL Green prior to being enclosed.
DECLARATION STATEMENT
Res
1 certify under penalty of perjury, under the laws of the State of California, the information
provided is true and correct.
1 certify that the installed measures, materials, components, or manufactured devices identified
on this certificate conform to all applicable codes and regulations, and the installation is
consistent with the plans and specifications approved by the enforcing agency.
Tanner Groseclose
Sd"/9619
Forms\CALGreen Documentation Compliance Cert Form 1-2017
Signature:
fiaakli Y' e-w6st,4n,
Position/Title:
Assistanat Superintendent