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1509000111 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 833 COTTONWOOD DR CONTRACTOR: DOMITROWICH JOSEPH PERMIT NO: 15090001 R ET AL OWNER'S NAME: DOMITROWICH JOSEPH R ET AL 833 COTTONWOOD DR DATE ISSUED: 09/01/2015 OWNER'S PHONE: 4082551259 CUPERTINO, CA 95014-4621 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL ❑ REPLACE MAIN ELECTRICAL PANEL (200 AMP). 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 Sq. Ft Floor Area: Valuation: $1500 performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this APN Number: 36917033.00 Occupancy Type: 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 WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save 180 DAYS FROM LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the �L, / Issued by: k Date: granting of this permit. Additionally, the applicant understands and will comply / ( f7 with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. RE -ROOFS: Signature Date All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. ❑ OWNER -BUILDER DECLARATION Signature of Applicant: Date: 1 hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER 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 & Professions Code) 1, 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 declarations: Health & Safety Code, Section 25532(a) should I store or handle hazardous I have and will maintain a Certificate of Consent to self -insure for Worker's 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 performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Sectio , 2553 nd 255 Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized agent: ' Date: 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 Compensation laws of California. If, after making this certificate of exemption, I CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code, I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued (Sec. 3097, Civ C.) 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, costs, and expenses which may accrue against said City in consequence of the 1 understand my plans shall be used as public records. granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section Licensed Professional 9.18. e— Date C Signatur .: CUPERTINO GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 950143255 MISC (408) 777-3228 • FAX (408) 777-3333 • buildina(a.cuDertino.ora l�O q�� / PLUI'MINC, Elwr F maL I I CTMCAL MSCELL-ANEOUS PROJECT ADDRESS 7� Z APN # )_ 3 OWNERNAME PHONE E•MAI STREET ADDRESS G /' C11Y /, ZIP (/ ` F CONTACT NAME PHO.-�7�, G EMAIIy/�/// - f STREETADDRES CITY, STATE, ZIP �` F r�lr OWNER ❑ OWNER -BUILDER ❑ OWNERAGENT ❑ CONTRACTOR ❑CONTRACTORAGENT ❑ ARCHITECT ❑ ENGINEM ❑ DEVELOPER ❑ TENANT CONTRACTOR NANO LICENSE NUMBER LICENSE TYPE BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARCHITECT/ENGINEER NAME LICENSE NUM 3ER BUS. LIC # COMPANY NAME E-MAIL FAX STRICT ADDRESS CITY, STATE, ZIP PHONE USE OF M MUL-nFAMrLy BUILDING: t3 COMm:ERCIAL PROIECI1RWZFLAm Q Yix FROIECS IN {� YFS URBAN JNI'ERFACE AREA NO FLOOD ZONE NO rl"maim AN 1] S -YES Ercmmt Bomm R NO DESCRIPTION OF WORK TOTAL VALUATIox —/ s' aid iiir �...� .. :t �, . ' -r:• .��. By my signature lAow, I certify to each of the following: I= the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have proyidedis correct I ave read the Description of Work and verify it is accurate. I agree to comply With all applicable local ordinances and state laws mlatizg t authorszs yrs nfS rpcitino-to_enter abme. mpelty-for inspection purposes. Signature of Applicant/Agent: , Date: J SUPPLEMENTAL INFORMATION REQUIRED :. .. ate... -�, Vit.• � '�„' -o i A,fEPMiscApp_2011.doc revised 06121/11 CITY OF CUPERTINO I/VI FEE ESTIMATOR — BUILDING DIVISION imADDRESS: 833 COTTONWOOD DR DATE: 09/01/2015 REVIEWED BY: SEAN UNITS APN: BP#: *VALUATION: 1$1,500 *PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Duplex USE: Amps PENTAMATION 1 REAP2 PERMIT TYPE: WORK REPLACE MAIN ELECTRICAL PANEL 200 AMP). SCOPE .Sztppl. lash Fee APPLIANCE / EQUIP TYPE FEE ID Phwlb. 1,14in ( heck QTY UNITS BP FEES Elec. Permit Fee: IEPERMIT Services 1 ERT<200 Other Elea Insp. 0.0 hrs $48.00 200 Amps $48 Permit 1,(W. .Sztppl. lash Fee PME Unit Fee: $48.00 PME Permit Fee: $48.00 (7onstruelion Tux. F Administrative Fee: (ADMIN $45.00 Work Without Permit? 0 Yes O No $0.00 TOTALS: Travel Documentation Fee: ITRA VDOC $48.00 Strong Motion Fee: IBSEISMICR NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District. etc.). These fees are based on the Preliminary information available and are only an estimate. Contact the Dept for addh7 info. FEE ITEMS (Fee Resolution 11-053 Eff.' 7/1/13) 11ech. Plan Check Phwlb. 1,14in ( heck Elec. Plan Check 0.0 hrs $0.00 Meeh. Permit Fee: P111mb. Permir Fee. Elec. Permit Fee: IEPERMIT Other Aaecla. Incl>, Other Plumb bl"p Other Elea Insp. 0.0 hrs $48.00 ,,,,. lee: Phimb. Insp. Fcc. $0.00 NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District. etc.). These fees are based on the Preliminary information available and are only an estimate. Contact the Dept for addh7 info. FEE ITEMS (Fee Resolution 11-053 Eff.' 7/1/13) FEE QTY/FEE MISC ITEMS Platy C./neck Fee: Suppl, P(' Fee PME Plan Check: $0.00 Permit 1,(W. .Sztppl. lash Fee PME Unit Fee: $48.00 PME Permit Fee: $48.00 (7onstruelion Tux. F Administrative Fee: (ADMIN $45.00 Work Without Permit? 0 Yes O No $0.00 .4c/ranced Planning Fees: Travel Documentation Fee: ITRA VDOC $48.00 Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $190.50 $0.00 TOTAL FEE: 1 $190.50 Revised: 07/02/2015 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 aacupertino.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 35 �/ T12 . APN f (7�y -3BP# OWNER NAME OWNER ADDRESS �dscgaz DESCRIPTION OF WORK: W5_ 41L 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. 2. 1 understand building permits are not required to be signed by property owners unless they are responsible for #he" nstruction and are not hiring a licensed Contractor to assume this responsibility. . 1 understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may t 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 umbers on permits and contracts. olx I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the tt'a. alue of my construction is at least five hundred dollars ($500), including labor and materials, I may be ered an "employer' under state and federal law. -I understand if I am considered an "employer" under state and federal law, I must register with the state and deral government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment compensation for each "employee." 1 also understand my failure to abide by these laws may subject me to serious financial risk. yI 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. 8. 1 understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for ny financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the workmanship or materials. OwnerBuilderForm 2010.doc revised 04/14/10 oI understand I may obtain more information regarding my obligations as an "employer" from the Internal ue 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 (CS LB) at 1-800-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed T,gamj_�thh aa%ctors. �O.I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I party legally and financially responsible for proposed construction activity at the site address listed above. .1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide pplicable laws and requirements that govern Owner -Builders as well as employers. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the formation 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 acceptable to the city may be required to be presented when the permit is issued to verifv the property owner's signatur,e�'�/2 ^ Z Property Owner's Signature: &Zl/ �- Date: ��1/�� --------------------------------------------------------------------------------------------------------------------------------------------- (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 owner's 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 owner's signature. Property Owner's Signature: Date: OwnerBuilderForm 2010.doc revised 04/14/10 CUPERTINO CONTRACTOR / SUBCONTRACTOR LIST Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 Fax: 408-777-3333 JOB ADDRESS: 3 PERMIT # / OWNER'S NAME: PHONE # GENERAL CONTRACTOR: BUSINESS LICENSE # ADDRESS: CITY/ZIPCODE: *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SU CO CT RS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. �— I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: V SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring / Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner / Contractor Signature Date WATER -CONSERVING PLUMBING FIXTURES OWNER CERTIFICATE OF COMPLIANCE COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 FILE 'I -> ),6 Owner N Address 1. Is your real property a registered historical site? ❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form. P"No Go to Question 2. Does your real property have a licensed plumber certifying that, due to the age or configuration of the property 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. / Skip the rest of the form and sign bottom of form. M No Go to Question 3. 3. Is water service permanently disconnected for your building? ❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form. "o Go to Question 4. 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 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form. 9H�Yes My real property is built and available for use or occupancy on or before January 1, 1994. Civil Code Sections 1101.1 through 1101.8 apply. Check one of the three following statements and sign bottom of form.. Plpase check ONE of the following: My property 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 to be replaced with water -conserving plumbing fixtures throughout the building. On or before January 1, 2017, all non- compliant plumbing fixtures shall be replaced with water -conserving plumbing fixtures (regardless of whether property undergoes alterations or improvements). ❑ My property is a multifamily 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 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). I, as the owner or owner's agent of this property, certify under penalty of perjury that non-compliant plumbing fixtures will be replaced prior to date specified above with water -conserving plumbing fixtures in accordance with Civil Code Sections 110 1. 1 through 1101.8, the current California Plumbing Code and California Green Building Standards Code, and manufacturer's installation requirements, and that the water -conserving plum mg fixtures comply with the requirements as indicated in the table on the following paize. /% Owner or Owner Agent's Signature: Date: Date: %/%//T 11� Upon completing and signing this C ificate, please return it to the Building Division in order to final your b ilding permit. SB407 2015.doc revised 08126/15 BUILDING PERMIT CANNOT BE FINALED AND COMPLETED UNTIL THIS CERTIFICATE HAS BEEN SIGNED AND RETURNED TO THE BUILDING DIVISION 1. it the existing plumbing fixture water usage/flow rate is equal to or lower than the figure shown, it is not required to be upgraded. SB407 2015.doc revised 08/26/15 Non -Compliant Water -Conserving Plumbing Fixture PlumbingFixture (Fixture Complying with Current Code Applicable to New Construction) Fixture Type Maximum Water Usage/Flow Rate 2013 CPC Ch. 4 2013 CPC Ch. 4 2013 CPC Ch. 4 Water Usage /Flow Rate 2013 CALGreen Div. 4.3 2013 CALGreen Div. 4.3 2013 CALGreen Div. 5.3 Single -Family Multi -Family Commercial Residential Residential Water Closets Exceed 1.6 Single flush toilets: 1.28 gallons/flush (Toilets) Gallons/flush Dual flush toilets: 1.28 gallons/flush effective flush volume (the composite, avers a flush volume of two reduced flushes and one full flush Urinals Exceed 1.0 Gallons/flush 0.5 gallons/flush Showerheads 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 exceed 2.0 gallons per minute @ 80 psi, or the shower shall be designed to allow onlyone 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 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 per minute @ 60 psi 1.8 gallons per minute 60 psi Faucets — Exceed 2.2 gallons 1.8 gallons per minute @ 1.8 gallons per minute 1.8 gallons per minute @ 60 Kitchen 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 @ default to maximum 60 psi, and must 1.8 gallons per minute @ default to maximum 60 psi 1.8 gallons per minute Where faucets meeting @ 60 psi the above are unavailable, Where faucets meeting aerators or other means the above are may be used to achieve unavailable, aerators or reduction. other means may be used to achieve reduction. 1. it the existing plumbing fixture water usage/flow rate is equal to or lower than the figure shown, it is not required to be upgraded. SB407 2015.doc revised 08/26/15 El 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 • buildingCcDcupertino.org FILE U2,r c!` _ Permit No. Z.� /2 19MV1 Address �j �l /j%L'�/(� # of Alarms Smoke: -f- Carbon Monoxide: / PERMIT CANNOT BE FINALED AND COMPLETED UNTIL THIS CERTIFICATE HAS BEEN SIGNED AND RETURNED TO THE BUILDING DIVISION 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. 1 have read and agree to compJv with the terms and conditions of this statement Owner (or Owner Agent's) Name:� Jar- C?fwl / �'Cwl Cf/ � C� q Si nature.......' ... Date: Contractor Name: Signature...................................................................Lic.#...................................... Date: ................... Smoke and CO form.doc revised 03/18114