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4�,wp.oa ' CITY OF NEWPORT BEACH
Community Development Department I Building Division
n 100 Civic Center Dr. 1 P.O. Box 1768 1 Newport Beach, CA 92658
a www.newoortbeachca.gov 1 (949) 644-3200
��1:/NORLT
CALGREEN DOCUMENTATION COMPLIANCE CERTIFICATION
ADDRESS: "(l /��S �� PERMIT NO.: aA2 B 1� }
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 fortheplanning and
design portion of the project.
REQUIRED DOCUMENTATIONS PROVIDED TO THE PROPERTY OWNER(S)
® Franchise Hauler for Construction/Demolition Waste (65% mina reuse of nonhazardous waste)
:"' OC Contents Limitation
Formaldehyde Emissions Limitation
Ei T-24 Energy Certificate of Installations (Env., QII, Lighting, Photovoltaic, Mach., Plumb.)
12(T-24 Energy Certificate of Verifications or Acceptance ( Env., QIi, Lighting, Photovoltaic, Mach.,
Plumb., HERS)
Operations and Maintenance Manual
MOISTURE CONTENT OF BUILDING MATERIAL (RESIDENTIAL CONSTRUCTION ONLY)
92/1 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
I 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.
lca, L
YaLC JII,IICY. / rvORwlu I IOU,
/6 C y ( ,�)uli-t. / f"-c 4,
Forms\CALGreen Documentation Compliance Cert Form 1-ZU17