Cx Measures in Construction Documents Compliance Form – Above Green

The following form may be required to be printed on the permit set of construction drawings or submitted separately.
CALGreen Commissioning Requirement 5.410.2, Commissioning Measures in the Construction Documents
5.410.2. Commissioning measures shall be shown in the construction documents.
The commissioning measures shown in the construction documents include the checked elements listed below and have been approved by the owner, owner's representative or designer of record.

	COMMISSIONING MEASURE ELEMENTS¹	INCLUDED
1.	Measures shown in the specifications and cross referenced	□
2.	List of commissioned equipment and systems	□
3.	Cx roles and responsibilities of all parties	□
4.	Meeting requirements	□
5.	Commissioning schedule management procedures	□
6.	Procedures for addressing outstanding issues or noncompliance	□
7.	Requirements for execution and documentation of installation and equipment start-up	□
8.	Specific testing requirements for each system type1	□
9.	Submittal review and approval requirements	□
10.	Contents and approval process of the commissioning plan	□
11.	Cx documentation and reporting requirements	□
12.	Facility staff training requirements and verification procedures	□
13.	O&M manual review and approval procedures	□
14.	Systems manual development and approval procedures	□
15.	Definitions	□

¹ These are not the detailed step-by-step test procedures but are lists of features, elements, modes, and conditions of tests for specific equipment.


Owner/Owner's Representative or Designer of Record Signature		Date

Cx MEASURES IN CONSTRUCTION DOCUMENTS

INCORPORATE THIS FORM IN THE PLANS

Project Address: _________________________________________________________
Permit Number: _____________________________

ITEM #	COMMISSIONING MEASURES ITEMS
1	Measures shown in the specifications and cross referenced
2	List of commissioned equipment and systems
3	Cx roles and responsibilities of all parties
4	Meeting requirements
5	Commissioning schedule management procedures
6	Procedures for addressing outstanding issues or noncompliance
7	Requirements for execution and documentation of installation and equipment start-up
8	Specific testing requirements for each system type
9	Submittal review and approval requirements
10	Contents and approval process of the commissioning plan
11	Cx documentation and reporting requirements
12	Facility staff training requirements and verification procedures
13	O&M manual review and approval procedures
14	Systems manual development and approval procedures
15	Definitions

Commissioning Agent Acknowledgment
I have reviewed the construction documents listed above and verified their compliance with the Owner's Project Requirements (OPR), Basis of Design (BOD), and commissioning plan.
Name: _______________________________
Company Name (if applicable): _______________________________
Agent's Signature: _______________________________	Date: ___________