14120086CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 7738 OAK MEADOW CT
CONTRACTOR: SOHINI RAJPAL
PERMIT NO: 14120086
OWNER'S NAME:
CUPERTINO, CA 95014
PHONE NO:
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
❑ LICENSED CONTRACTOR'S DECLARATION
INSTALL 159 FT OF GAS LINE
License Class Lic. #
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9
(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
Valuation: $4000
performance of the work for which this permit is issued.
Sq. Ft Floor Area:
I have and will maintain Worker's Compensation Insurance, as provided for by
APN Number: 36626010 00
Occupancy Type:
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
PERMIT EXPIRES IF WORK IS NOT STARTED
correct. I agree to comply with all city and county ordinances and state laws relating
WITHI PERMIT ISSUANCE OR
to building construction, and hereby authorize representatives of this city to enter
180 DA S FRO LA T CALLED INSPECTION.
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
in of the
12, 1 y
costs, and expenses which may accrue against said City consequence
Issued by: Date:
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9 18.
RE -ROOFS:
Date
All roofs shall be inspected prior to any roofing material being installed. If a roof is
Signature
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
❑ OWNER -BUILDER DECLARATION
Signature of Applicant: Date:
` I hereby affirm that I am exempt from the Contractor's License Law for one of
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
the following two reasons:
I, as owner of the property, or my employees with wages as their sole compensation,
do the work, and the structure is not intended or offered for sale (Sec.7044,
will
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
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
I hereby affirm under penalty of perjury one of the following three
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Code, Section 25532(a) should I store or handle hazardous
declarations:
I have and will maintain a Certificate of Consent to self -insure for Worker's
Health & Safety
material. Additionally, should I use equipment or devices which emit hazardous
Compensation, as provided for by Section 3700 of the Labor Code, for the
air contaminants as defined by the Bay Area Air Quality Management District I
will maintain compliance with th fCupertino Municipal Code, Chapter 9.12 and
performance of the work for which this permit is issued.
Worker's Compensation Insurance, as provided for by
the Health & Safety Code, Secti s 25505, 25533, and 25534.
I have and will maintain
Section 3700 of the Labor Code, for the performance of the work for which this
Owner or authorized agent: Date: 1y
permit is issued.
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
CONSTRUCTION LENDING AGENCY
Compensation laws of California. If, after making this certificate of exemption, I
I
I hereby affirm that there is a construction lending agency for the performance of
become subject to the Worker's Compensation provisions of the Labor Code, must
work's for which this permit is issued (Sec. 3097, Civ C )
forthwith comply with such provisions or this permit shall be deemed revoked.
Lender's Name
APPLICANT CERTIFICATION
Lender's Address
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 city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
which may accrue against said City in consequence of the
I understand my plans shall be used as public records.
costs, and expenses
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations pthe Cupertino Municipal Code, Section
Licensed Professional
9 18.
Signature Date
CUPERTINO
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION rrllV�
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 t �v
(408) 777-3228 • FAX (408) 777-3333 • building cDcupertino.orq
PROJECT ADDRESS '�7 `j wC\ }� �� � � G- I ' APN # '5LO LP 2,L"10'"'
OWNER NAME PHONE
FAX
CONTACT NAME PHONE E-MAIL
STREET ADDRESS CITY, STATE, ZIP FAX
MEP
MISIC
❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME u A - n , b L ce-- LICENSE NUMBER (?777 / I I d' LICENSE TYPE BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
USE OF ❑ SFD or DUPLEX ❑ MULTI -FAMILY
BUILDING: ❑ COMMERCIAL
PROJECT IN WILDLAND ❑ YES
URBAN INTERFACE AREA ❑ NO
PROJECT IN ❑ YES
FLOOD ZONE ❑ NO
IS TIM BLDG AN ❑ YES
EICHLER HOME? ❑ NO
DESCRIPTION OF WORK
TOTAL VALUATION: e4j V (> D - OFb�R CEIYED BY
a
By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the pr a f I have read this
application and the information I have provided is correct. 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 build' g construction. I authorize representatives of Cupertino to enter the above-ide tified perty for inspection purposes.
Signature of Applicant/Agent: Date:
121-67/4pr�l4
SUPPLEMENTAL INFORMATION REQUIRED`' OFFICE USE ONLY
MEPMiscApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 7738 oak meadow ct DATE: 12/17/2014 REVIEWED BY: Mendez
APN: BP#: *VALUATION: $4,000
*PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration / Addition / Repair
------TPRIMARY PENMIT TY ON 1 RPGAS
USE: SFD or Duplex PERMIT TYPE:
WORK install 159 ft of gas line
SCOPE
APPLIANCE / EQUIP TYPE
FEE ID
"n
QTY
UNITS
BP FEES
Piping, Gas >4 Outlets
1BPGAS
1
#
$72
TOTALS: I I I = N $72.00
I
"n
-bac)
Plumb. Plan Check
0.0
hrs $0.00
Ale"'. 1'1tz� Check
itac;li. F'i>jn1it Fee.'
Plumb. Permit Fee: IPPERMIT
/-lac.' 1>....
Odwr I fetch. frim
Other Plumb Insp.
0.0
hrs
$48.00
offer kfe('. '2'V".
P17111tf'7. his7. Fee:
IJC(" 117st, Fl -"e
does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
NOTE: This estimate
District, etc.. These fees are based on the prelimina information available and are only an estimate. Contact the Dept for addn'1 info.
FEE ITEMS (Fee Resolution 11-053 Eff. 7/1/13)
FEE
QTY/FEE
MISC ITEMS
--F--=
Lf,L, VII,. t}°.. "'I'C
A
PME Plan Check:
$0.00
e
sliloj. l . 1 rs j:7 Fee
PME Unit Fee:
$72.00
PME Permit Fee:
-T77t=
$48.00
(.'o sflwc tion ox:
Administrative Fee:
]ADMIN
$45.00
Work Without Permit?
® Yes (E) N0
$0.00
:AJI?fclil"'Cd 111ann rrg Fees:
Travel Documentation Fee:
1TRAVDOC
$48.00
Strom Motion Fee:
IBSEISMICR
$0.52
Select an Administrative Item
Bldg Stds Commission Fee:
1BCBSC
$1.00
$214.52
$0-00% TOTAL FEE:
$214.52
Revised: 10/01/2014
CUPERTINO
OWNER -BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building(a�cupertino.org
Dear Property Owner(s):
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified at:
SITE ADDRESS.,n25Q ow Mt-nOvi
C111PN
BP#
OWNER NAME
to 7HREiF tDOTLETS.
We are providing you with an Owner -Builder Acknowledgment and Information Verification Form to make you aware of
your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner -Builder. We
will not issue a building permit until you have read, initialed your understanding of each provision, signed, and
returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless
you, the property owner, obtain the prior approval of the permitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
(DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information.)
1. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -
Builder" building permit that erroneously implies that the property owner is providing his or her own labor and material
personally. 1, as an Owner -Builder, may be held liable and subject to serious financial risk for any injuries sustained by
an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not
provide coverage for those injuries. I am willfully acting as an Owner -Builder and am aware of the limits of my
insurance coverage for injuries to workers on my property.
Y _ 2. 1 understand building permits are not required to be signed by property owners unless they are responsible for
the construction and are not hiring a licensed Contractor to assume this responsibility.
\�1_3. 1 understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may
protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
name instead of my own.
�? 4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
5. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be
considered an "employer' under state and federal law.
`',, 6. 1 understand if I am considered an "employer" under state and federal law, I must register with the state and
federal government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to
unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject
me to serious financial risk.
V?, 7. 1 understand under California Contractors' State License Law, an Owner -Builder who builds single-family
residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by
licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work
is performed under contract with a licensed general building Contractor.
V, 8. 1 understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for
any financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction
defects in the workmanship or materials.
OwnerBuildeYForm 2010.doc revised 04/14/10
N i 9. 1 understand I may obtain more information regarding my obligations as an "employer" from the Internal
Revenue Service, the United States Small Business Administration, the California Department of Benefit Payments,
and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State
License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed
contractors.
1
P'- 1 10. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I
am the party legally and financially responsible for proposed construction activity at the site address listed above.
V11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
by all applicable laws and requirements that govern Owner -Builders as well as employers.
!'• 12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
information I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If
you contract with someone who does not have a license, the Contractors' State License Board may be unable to
assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed
Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or
employee of that individual or firm is injured while working on your property, you may be held liable for damages. If
you obtain a permit as Owner -Builder and wish to hire Contractors, you will be responsible for verifying whether or not
those Contractors are properly licensed and the status of their workers' compensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS: Please complete the following construction lending agency information.)
I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued
(Sec 3097 Civ.)
Lender Name: Lender Address:
Before a building permit can be issued, this form must be completed and signed by the property owner and
returned to the agency responsible for issuing the permit. Note: A copy of the property owner's driver's license,
form notarization, or other verification ac eptable to the city may be required to be presented when the permit is issued
to verify the property owner's signature.
Property Owner's Signature:_Date: o
---------------------------------------------------------------------------------------------------------------------------------------------
(NOTE: The following Authorization Form is required to be completed by the property owner only when designating an
agent of the property owner to apply for a construction permit for the Owner -Builder).
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby
authorize the following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an
Owner -Builder Permit for my project.
Scope of Construction Project (or Description of Work):
Project Location or Address:
Name of Authorized Agent:
Address of Authorized Agent:
Tel No
I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the
above information and certify its accuracy. Note: A copy of the property owners driver's license, form notarization, or other
verification acceptable to the city may be required to be presented when the permit is issued to verify the property owners
signature.
Property Owner's Signature:
Date:
avnerBuildeYForm 2010.doc revised 04/14/10
gam- k:WIS Mo To Sl%4'� .h=
L[L-#'. °-7% �11—
Proposed gas pipeline for 7738 Oak Meadow Ct,
Meter
,t
Cupertino
Section 1: run length = 28', demand 22k BTU, pipe size W
Section 2: run length = 83', demand 99k BTU (67k + 32k), pipe size %"
Section 3: run length =10', demand 67k BTU, pipe size %2"
Section 4: run length = 38, demand 32k BTU, pipe size %2"
Outlet C is a 22k BTU dryer
Outlet D is a 67k BTU range
Outlet E is a 32k BTU fireplace
Existing line not being modified.
1 4-,'aA 4L.S 4 6 kQMJJ S ED
Ga76s
—Zs�>t3 CGC
i t CPC—
CU�aao t�-4Jnl% Coop
i`
CVPrRTI.I O.
WATER -CONSERVING PLUMBING FIXTURES FILE
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building(a,cupertino.org
Owner Name Permit No. l
Address 7%�'-rJ L(� c,/ , C,0 PE� l 1�
Please refer to the attached California Civil Code Sections 1101.1— 1101.8 which are part of this Certification form.
1. Is your real property a registered historical site?
❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Sign below and skip the rest of the form.
ate
OvSrgnatuire„ sp:
F o 'Go-to°Question 2.
2. Does your real property have a licensed plumber certifying that, due to the age or configuration of the properly or its
plumbing, installation of water -conserving plumbing fixtures is not technically feasible?
❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply.
❑ The licensed plumber's certification has been provided to the Building Division.
Sign below and skip the rest of the form.
Ow'�er�'Srgnat � _
o o Go to QuV,
estion 3.
3. Is water service permanently disconnected for your building?
❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply.
�.---�
bwner�SrgnaidT
Go to Question.4.
Sign below and skip the rest of the form.
r Date o s1J C)
4. Is your real property built and available for use or occupancy on or before January 1, 1994?
❑ No My real property is built and available for use or occupancy after January 1, 1994.
Civil Code Sections 111.1 through 1101.8 do not apply. Sign below and skip the rest of the form.
,fo
O merS;rgnature; Date,, OrC' // Di
Yes My real property is built and available for use or occupancy on or before J uatyy 1, 994.
Civil Code Sections 1101.1 through 1101.8 apply. Refer to the attached.
M-Myproperty is a single family residential real property. See Civil Code Section 1101.4.
On and after January 1, 2014, building alterations or improvements shall require all non-compliant plumbing
fixtures do be replaced with water -conserving plumbing fixtures throughout the building. On or before January 1,
201 alorr-cdinpliant plumbing fixtures shall be replaced with water -conserving plumbing fixtures (regardless
%N11l property undergoes alterations or improvements).
❑ My property is a multifatnily residential real property. See Civil Code Section 1101.5.
On and after January 1, 2014, specified building alterations or improvements shall require non- compliant
plumbing fixtures to be replaced with water -conserving plumbing fixtures.
On or before January 1, 2019, all non-compliant plumbing fixtures shall be replaced with water-
conserving plumbing fixtures throughout the building (regardless of whether property undergoes alterations or
improvements).
❑ My property is a commercial real property. See Civil Code Section 1101.5.
On and after January 1, 2014, specified building alterations or anprovernents shall require non- compliant
plumbing fixtures to be replaced with water -conserving plumbing fixtures.
SB4072015.doc revised 02/04/15
On or before January 1, 2019, all non-compliant plumbing fixtures shall be replaced with water- conserving
plumbing fixtures throughout the building (regardless of whether property undergoes alterations or
` '"`�'im`provements).
UWe, the owner(s) of this property, certify under penalty of perjury that non-compliant plumbing fixtures wi1be replaced
prior to date specified above with water -conserving plumbing fixtures in accordance with Civil Code Sections 1101.1 through
1101.8, the current California Plumbing Code and California Green uilding Standards Code, and manufacturer's installation
requirements, and that the water -conserving plumbing fixtures comjAy with the requirements as indicated in the table below.
Ow. --6s (or Owner Agent's) Signature: 4 :. 3k Date: Q, D
Upon completing and signing this Certificate, please return it to the Building Division in order to final your pen -nit.
/ the existing plumbing fixture water usage/flow rate is equal to or lower than the figure shown, it is not required to be upgraded.;,
SB40 7 2015.doe revised 02/04115
aIVonComplantixtur
'` Water -Conserving Plumbing Fixture
rPlumbin Fe
' (Fixture Complying with Current Code Applicable to New Construction)
'
Maximum Water Usage/Flow Rate
Fixture Typei'
.`•1-
Water Usage
2013 CPC Ch. 4
2013 CPC Ch. 4
2013 CPC Ch. 4
r.;
r !
Rate
2013 CALGreen Div. 4.3
2013 CALGreen Div. 4.3
2013 CALGreen Div. 5.3
� Single -Family
Multi -Family
Commercial
;,�/Flow
► :
Residential
Residential
Water Closet`s-;
n Exceed 1.6
Single flush toilets: 1.28 gallons/flush
(Toilets)'
1Gallons/flush i ::'
Dual flush toilets: 1.28 gallons/flush effective flush volume (the composite,
average flush volume of two reduced flushes and one full flush
Urinals i_ .
I Exceed 1.0 _
0.5 gallons/flush
l Gallons/flush
Showerheads .
t Exceed 2.5
2.0 gallons per minute @ 80 psi. Also certified to the performance criteria of
.'
;gallons per minute '
U.S. EPA WaterSense Specification for Showerheads
=
(A hand-held shower is considered a showerhead.)
For multiple showerheads serving one shower, the combined flow rate of all
-
showerheads and/or other shower outlets controlled by a single valve shall not
F =
exceed 2.0 gallons per minute @ 80 psi, or the shower shall be designed to
I
allow only one shower outlet to be in operation at a time.
Faucets —
;Exceed 2.2 gallons : ?
Maximum 1.5 gallons per
Within units:
0.5 gallons per minute @ 60
Lavatory ,
:,'Per minute w
minute @ 60 psi; minimum
Maximum 1.5 gallons
psi
Faucets _::'
0.8 gallons per minute @
per minute @ 60 psi;
20 psi
minimum 0.8 gallons
per minute @ 20 psi
In common and public
use areas: 0.5 gallons
=1
_ '
per minute @ 60 psi
'
1.8 gallons per minute
@ 60 psi
Faucets — i- <
I Exceed 2.2 gallons ?
1.8 gallons per minute @
1.8. gallons per minute
1.8 gallons per minute @ 60
Kitchen ;, .
k per minute
60 psi
@ 60, psi
psi
Faucets
May temporarily increase
May temporarily
up to 2.2 gallons per
increase up to 2.2
minute @ 60 psi.and must
; gallons per minute @
-f
default to, maximum
60 psi, and must
.1.8 gallons per minute.@ .
.efault,to,maximum
60 psi
1.8 gallons per minute
q
Where faucets meeting
@ 60.psi
the above are unavailable,
;Where:faucefs meeting
aerators or other'means
thea bove are_ .;
may be'used to. achieve
unavailable, aerators or
reduction
other means may be
ti
used to achieve
�
reduction.,.
/ the existing plumbing fixture water usage/flow rate is equal to or lower than the figure shown, it is not required to be upgraded.;,
SB40 7 2015.doe revised 02/04115
Address
SMOKE / CARBON MONOXIDE ALARMS
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building(alcupertino.org
Carb
PURPOSE
This affidavit is a self -certification for the installation of all required Smoke and Carbon Monoxide Alarms for
compliance with 2013 CRC Section R314,2013 CBC Sections 420.6 and 907.2.11.2 where no interior access for
inspections are required.
GENERAL INFORMATION
Existing single-family and multi -family dwellings shall be provided with Smoke Alarms and Carbon
Monoxide alarms. When the valuation of additions, alterations, or repairs to existing dwelling units exceeds
$1000.00, CRC Section R314 and CBC Sections 907.2.11.5 and 420.6 require that Smoke Alarms and/or Carbon.
Monoxide Alarms be installed in the following locations:
AREA
SMOKE ALARM
CO ALARM
Outside of each separate sleeping area in the immediate vicinity of the
bedroom(s)
X
X
On every level of a dwelling unit including basements
X
X
Within each sleeping room
X
Carbon Monoxide alarms are not required in dwellings which do not contain fuel -burning appliances and that
do not have an attached garage. Carbon monoxide alarms combined with `smoke alarms shall comply with
CBC Section 420.6 and shall be approved by the Office of the State Fire Marshal.
Power Supply: In dwelling units with no commercial power supply, alarm(s) may be solely battery operated.
In existing dwelling units, alarms are permitted to be solely battery operated where repairs or alterations do
not result in the removal of wall and ceiling finishes or there is no access by means of attic, basement or crawl
space. Refer to CRC Section R314 and CBC Sections 907.2.11.4 and 420.6.2. An electrical permit is required for
alarms which must be connected to the building wiring.
As owner of the above -referenced property, I hereby certify that the alarm(s) referenced above has/have been
installed in accordance with the manufacturer's instructions and in compliance with the California Building
and California Residential Codes. The alarms have been tested and are operational, as of the date signed
below.
I have read and agree to co ly with the terms and conditions of this statement
Owner (rOwnerAgent's) :
Ij
�p
V
D
'.............................................................`i nature...................I
Contactor Name:
Signature.......... ............................................. ............ Lic.#...................................... Date:
Smoke and CO form.doc revised 03118114