15100016CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS: 22433 RIVERSIDE DR
OWNER'S NAME: SIRAVARA NAGENDRA AND SABITHA
OWNER'S PHONE: 4087184020
LICENSED CONTRACTOR'S DECLARATION
I.icense Class LiLic�# Of J 0 J/ f °!
Contractor v Date / Or/z � o
1 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.
1 hereby affirm under penalty of perjury one of the following two declarations:
t 1 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
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
permit is issued.
APPLICANT CERTIFICATION
I certify that 1 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
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply with
all non -point source r gulations per the pertino Municipal Code, Section 9.18.
Signature Date t 9L2/1/_6
❑ OWNER -BUILDER DECLARATION
hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
i. 1, 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)
2. 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
1 hereby affirm under penalty of perjury one of the following three declarations:
n. 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
performance of the work for which this permit is issued.
2. 1 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
permit is issued.
3. I certify that in the performance of the work for which this permit is issued, l 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
become subject to the Worker's Compensation provisions of the Labor Code, I
must forthwith comply with such provisions or this permit shall be deemed
revoked.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
correct. 1 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
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
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.
Signature Date
CONTRACTOR: VALLEY HEATING K PERMIT NO: 15100016
COOLING
1171 N 4TH ST DATE ISSUED: 10/02/2015
SAN JOSE, CA 95112 PHONE NO: (408)294-6290
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
REPLACE (E) FURNACE WITH (N) IN SAME LOCATION,
INSTALL (N) A/C UNIT IN SIDEYARD
Sq. Ft Floor Area: I Valuation: $11865
APN Number: 35603039.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 D S FROM LAST CALLED INSPECTION.
Issued by: �d�/`-t � Date: I Ob iX15
RE -ROOFS:
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.
Signature of Applicant: Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
1 have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should 1 store or handle hazardous material.
Additionally, should 1 use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Ilealth & Sa ety Code, Sections 25505, 25533, and 25534.
Owne authorized age�jty
Date:
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Add
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
g�
CUPERTINO
GENERAL PERMIT APPLICATION L=ISO
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • buildinc(cDcuoertino.oro
17 PLU>`IBLNG 7 MECHANICAL n ELECTRICAL n I`475(.FLi.A?. r nl ;:
FRC7--CTADDF. SS--
(J�
0 WATER NAME ( /- PH hE E -NAIL
STREET ADDRESS CITY, STATE, ZIP I FAX
CONTACT NAME PHONE E-MAIL
n�rr"cror
STREET ADDRESS
CITY, ST.ATE, ZIP
FAX
❑ OWNER ❑ OWNER-BUIIAER ❑ OWMMAGENTT CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ D7 -\ELOPER ❑ TENaNT
CONTRACTOR NA EE t 1 LIC E SE `UA2BER
LICENSE TYPE \
BUS. LIC
COMPANY NAME
E MAIL � r i I � 11u I I � C J M
I FAX
L
STREET ADDRESS I /�r T h `(t
/ v ) T
CITY, STATE, ZIP C �^ �C jc
J
PHONE G `'('a 7 `� U
6
ARCHITECT/ENGINEER NAME LICENSE NUMBER
BUS. LIC R
COMPANY NAME
E-MAIL
FAY,
STREET ADDRESS
CITY, STATE, ZIP
PHONE
USE OF ❑SFD.,DUPLEX ❑ MULTI -FAMILY PROJECT LNWILDLAND ❑ YES PROJECT IN ❑ YES
BLIII.DDJG: ❑ COMKMCIAL URBAN D,=ACE AREA ❑ NO FLOOD ZONE ❑ NO
IS THEBLDG.AN ❑ YES
EICHLER HOME? ❑ NO
DESCRIPTION OF WORK -�L^rtlC IC4C,e)," `
I l
'lA� A
TOTAL VALUATION: 1 I RECD: D
By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. 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 ding construction. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes.
Si�atureofApplicanUAgent: e- Date: /
SUPPLEhIENTAL INFORMATION REQUIRED
OFFICE USE ONL
OVER-THE-COUNTER
- E.�'RESS
_
❑ STANDARD
r
L
MPPHiscApp_1011.doc revised 06121/11
CITY OF CUPERTINO I filWOl6
P"Iff FEE ESTIMATOR - BUILDING DIVISION v
APPLIANCE / EQUIP TYPE
ADDRESS: 22433 Riverside Drive
DATE: 10/02/2015
REVIEWED BY: PAUL
UNITS
APN: 356 03 039
BP#:
'VALUATION:
1$11,865
PERMIT TYPE: Mechanical Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY SFD or Duplex
USE:
$72
PENTAMATION FURN/AC
I PERMIT TYPE: A
WORK
Re lace E Furnace with N in Same Location Install N A/C unit in side and
SCOPE
1
APPLIANCE / EQUIP TYPE
FEE ID
I Li
QTY
UNITS
BP FEES
A/C Units (<=1 OK cfm)
1BREMAIR
1
#
$72
Furnace, Forced -Air
1MFR=<100
14 hrv) 1"cc
1
#
$143
PME Unit Fee:
$215.00
PME Permit Fee:
$48.00
Administrative Fee: 1.41)AHN
$45.00
Work Without Permit? 0 Yes 0 No
$0.00
TOTALS:
A
Travel Documentation Fee: ITRA I'DOC
$215.00
Strong Motion Fee: IBSEISHICR
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc.. Thesefees are based on the prelimina information available and are onh' an estimate. Contact the De t or addn'l info.
FEE ITEMS (l,cc Resolution 11-053 [JI.—' 1 131
Mech. Plan Check 0.0 hrs $0.00
Mech. Permit Fee: IMPERMIT
Other Mech. Insp. 0.0 hrs $48.00
I Li
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc.. Thesefees are based on the prelimina information available and are onh' an estimate. Contact the De t or addn'l info.
FEE ITEMS (l,cc Resolution 11-053 [JI.—' 1 131
FEE
QTY/FEE
MISC ITEMS
, Iti (71C, ,, . , . .
gyp/. PC 1"cc,
PME Plan Check:
$0.00
14 hrv) 1"cc
PME Unit Fee:
$215.00
PME Permit Fee:
$48.00
Administrative Fee: 1.41)AHN
$45.00
Work Without Permit? 0 Yes 0 No
$0.00
A
Travel Documentation Fee: ITRA I'DOC
$48.00
Strong Motion Fee: IBSEISHICR
$1.54
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
1 $358.541
$0.00 TOTAL FEE:
$358.54
Revised: 07/02/2015
.RECEIVED
0 2 2015
0N11W3dnC
ld30 JNINNV-ld
31ba
A8 (13>103HO SNIV 109d
aauueaSLueo Aq pauueaS
CUPERTINO
Building Department
r OCT 022015
REVIEWED FOR CODE!COMPLIANCE
Reviewed By: '?A#\Vaiwc w
OFFICE COPY
C'
s
PERMIT :�'j l�:bb/6 .
CQkUNITY DEVELOPM
NT DEPARTMENT
BCW -DING DIVISION
- CUPERTINO
r' APPROVED
This set of plans and specificati
is MUST be kept at the
job site during construction. It i
unlawful to make any
changes or alterations on
3ame, or to deviate
therefrom, without approval frc
in the Building Official.
The Stamping of this plan and s
ecifica' ons SHALL NOT
beheld to permit or to be an
prowl of the violation
of ai visions of any City
rdinance or State Law.
BY -%
_
PERMIT :�'j l�:bb/6 .
CERTIFICATE OF COMPLIANCE CF1R-ALT-02-E
Alterations to Space Conditioning Systems (formerly CF -IR -ALT -HVAC) (Page 1 of 3 )
Project Name: 2015- 0186 Nagendra Siravara I Date Prepared: 2015-09-17
r. r4 /^3 T T Z4
A. General Information
CF1R-ALT-02 is applicable to multiple space conditioning systems contained within a single dwelling unit. When multiple dwelling units must be documented,
use one CHR -ALT -02 document for each dwelling unit.
O1
Project Name
2015- 0186 Nagendra Siravara
02
Date Prepared
2015-09-17 t2�
03
Project Location
22433 Riverside Drive
04
Building Type
Single family
OS
CA City
Cupertino
06
Dwelling Unit Name
2015- 0186 Nagendra Siravara
SC System
SC System
CFA served
system a
Dwelling Unit Conditioned
Installing new SC
07
Zip Code
95014
08
Floor Area (ft2)
2200
by this SC
ducted
containing
system
Number of space conditioning
entirely new
09
Climate Zone
4
10
(SC) systems in this dwelling
1
component?
components?
feet of ducts?
duct system?
unit.
Alteration Type
B. Space Conditioning (SC) System Information
O1
02
03
04
05
06
07
08
09
10
Is the SC
Installing a
SC System
SC System
CFA served
system a
refrigerant
Installing new SC
Installing
Installing
Installing
Identification or
Location or Area
by this SC
ducted
containing
system
more than 40
entirely new
entirely new
Name
Served
System (ft2)
system?
component?
components?
feet of ducts?
duct system?
SC system?
Alteration Type
Furnace
Altered space
replacement add
whole house
2200
Yes
Yes
Yes
No
No
No
conditioning system
A/C
C. Extension of Existing Duct System, Greater Than 40 Feet (Section150.2(b)1Diib)
This section does not apply to this project.
Registration Number: 215-A6330170A-000000000-0000
Registration Date/Time: 2015-09-17 16:58:37
HERS Provider: CaICERTS
CA Building Energy Efficiency Standards - 2013 Residential Compliance Report Version: 2013-1.006 Report Generated: 2015-09-17 16:58:38
Schema Version: 0.555SDD
i
CERTIFICATE OF COMPLIANCE CF111-ALT-024
Alterations to Space Conditioning Systems (formerly CF -IR -ALT -HVAC) (Page 2 of 3 )
D. Altered Space Conditioning System (Sections 150.2(b)1E and F)
O1
02
03
04
05
06
07
08
09
10
11
12
Heating
Cooling
System
Heating
Altered
Heating
Minimum
Altered
Cooling
Minimum
Required
New or
Identification
System
Heating
Efficiency
Efficiency
Cooling
Cooling
Efficiency
Efficiency
Thermostat
Replaced
New Duct
or Name
Type
Components
Type
Value
System Type
Components
Type
Value
Type
Duct Length
R -Value
Furnace
Central gas
All new
Central split
All new
This field or
This field or
replacement
heating
AFUE
g
cooling
SEER
14
Setback
section is not
section is not
add A/C
furnace
components
AC
components
applicable
applicable
Required Documentation:
CF2R-MCH-01-E - Space Conditioning Systems Ducts and Fans
-Duct insulation requirement for new plenums: R6.
CF2R-MCH-20-H & CF3R-MCH-20-H - Duct Leakage testing required when heating or cooling components are installed in ducted systems, or when more than 40 ft of duct length is replaced.
-Leakage rate compliance: <- 15%, or <_ 10% leakage to outside, or seal all accessible leaks.
CF2R-MCH-25-H & CF3R-MCH-25-H Refrigerant Charge Verification required when refrigerant containing components are installed or altered (applicable in U 2, 8-15).
CF2RCF3R-MCH-23 & CF3R-MCH-23 Air Flow 2 300 CFM/ton required when MCH -25 is required.
Exceptions:
-Duct systems registered with HERS provider as previously sealed are exempt from MCH -20 Duct Leakage Testing requirements.
-Heating-only systems and Air Handler/Furnace changes do not require verification of Air Flow MCH -23, or Refrigerant Charge MECH-25.
-Existing duct systems constructed, insulated or sealed with asbestos are exempt from MCH -20 Duct Leakage Testing requirements.
E. Entirely New or Complete Replacement Duct System, with or without Equipment Changeout (Sections 150.2(b)iDiia and 150.2(b)IE, F)
This section does not apply to this project.
F. Entirely New or Complete Replacement Space Conditioning System (Section 150.2(b)1C)
This section does not apply to this project.
Registration Number: 215-A6330170A-000000000-0000
Registration Date/Time:
2015-09-17 16:58:37
HERS Provider: CaICERTS
CA Building Energy Efficiency Standards - 2013 Residential Compliance Report Version: 2013-1.006 Report Generated: 2015-09-17 16:58:38
Schema Version: 0.555SDD
CERTIFICATE OF COMPLIANCE CF1R-ALT-02-E
Alterations to Space Conditioning Systems (formerly CF -1R -ALT HVAC) (Page 3 of 3 )
Documentation Author's Declaration Statement
1. 1 certify that this Certificate of Compliance documentation is accurate and complete.
Documentation Author Name:
Documentation Author Signature: anc�
Faulkner, Cindy
C1'GZGGI/4/%/li
Company:
Signature Date:
ATKINSON CLIMATROLLERS INC dba VALLEY HEATING,COOLING & ELECTRICAL
2015-09-17 16:58:37
Address:
CEA/ HERS Certification Identification (if applicable):
1171 NORTH 4TH STREET
City/State/Zip:
Phone:
SAN JOSE CA 95112
(408) 294-6290
Responsible Person's Declaration statement
I certify the following under penalty of perjury, under the laws of the State of California:
1. The information provided on this Certificate of Compliance is true and correct.
2. 1 am eligible under Division 3 of the Business and Professions Code to accept responsibility for the building design or system design identified on this Certificate of Compliance (responsible designer).
3. That the energy features and performance specifications, materials, components, and manufactured devices for the building design or system design identified on this Certificate of Compliance conform to the
requirements of Title 24, Part 1 and Part 6 of the California Code of Regulations.
4. The building design features or system design features identified on this Certificate of Compliance are consistent with the information provided on other applicable compliance documents, worksheets,
calculations, plans and specifications submitted to the enforcement agency for approval with this building permit application.
5. 1 will ensure that a registered copy of this Certificate of Compliance shall be made available with the building permit(s) issued for the building, and made available to the enforcement agency for all applicable
inspections. I understand that a registered copy of this Certificate of Compliance is required to be included with the documentation the builder provides to the building owner at occupancy.
Responsible Designer Name:
Responsible Designer Signature:
Faulkner, Cindy
cf/
Company:
Date Signed:
ATKINSON CLIMATROLLERS INC dba VALLEY HEATING,COOLING & ELECTRICAL
2015-09-17 16:58:37
Address:
License:
1171 NORTH 4TH STREET
258540
City/State/Zip:
Phone:
SAN JOSE CA 95112
(408) 294-6290
Digitally signed by Ca10ERTS. This digital signature is provided in order to secure the content of this registered document, and in no way implies Registration Provider responsibility for the accuracy of the information.
Registration Number: 215-A6330170A-000000000-0000 Registration Date/Time: 2015-09-17 16:58:37 HERS Provider: CaICERTS
CA Building Energy Efficiency Standards - 2013 Residential Compliance Report Version: 2013-1.006 Report Generated: 2015-09-17 16:58:38
Schema Version: 0.555SDD
CUPERTINO
WATER -CONSERVING PLUMBING FIXTURES
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building(aDcupertino.org
Owner Name e. •� r� S'ac�na Vim• rte. ,
Permit No. d� $
Address v4Y.3 1%J e'
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 fonn.
Uf -No Go to Question 2.
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.
Dt -< 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.
UVo 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.
Kvl'es My real property is built and available for use or occupancy on or before January 1, 1994.
Civil Code Sections 110 1. 1 through 1101.8 apply. Check one of the three following statements and sign
bottom of form..
Please check ONE of the following:
]"y 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
iimprovements).
❑ 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 urrprovernents).
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 1101.1
through 1101.8, the current California Plumbing Code and California Green Building Standards Code, and manufacturer's
installation requirements, and that the water -conserving plumbing fixtures comply with the requirements as indicated in the
table on the following pane.
I Owner or Owner Agent's Signature: ��_�—P--�°'(.•.,� Date:
Upon completing and signing thi ertificate, please return it to the Building Division in order to final vour buildina hermit.
SB407 2015.doc revised 08/26/15
SMOKE / CARBON MONOXIDE ALARMS
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE a CUPERTINO, CA 95014-3255
(408) 777-3228 a FAX (408) 777-3333 • building(ftupertino.org
aim
aress a33 R\ V e r s; de �d� s �R�we-fr � :x w"ns�1 ,lie: -i_ > 1-M4t momi I
PERMIT CANNOT BE FI\i ALED AND COMPLETED UNTIL TINS CERTIFICATE
iIAS BEEN SX AND REjjjNLY{,D 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
)(
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: La 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 andagreeto comply with the terms and conditions of this statement
;Cisi tr_Q€ QE.ner _`gets)'I�aiaSe°
r ray-ih. yri__ - .................
..... I Name:. :Lic'#' ............... _Da'e:................
Smoke and CO_fa•n:.doc remised 03/18/14