The URL can be used to link to this page

15100241CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10310 CALVERT DR CONTRACTOR: ANTHONY LEWIS PERMIT NO: 15100241 OWNER'S NAME: JEFFREY AND JULIE LIN 1070 BIRD AVE DATE ISSUED: 10/30/2015 OWNER'S PHONE: 4086573799 SAN JOSE, CA 95125 PHONE NO: (408) 217-8621 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL Install (1) 50 Amp 240v Electrical Circuit for Nema 14-50 outlet with disconnect for A 1:s1(07 License Class& r- i fl Lic. # 1 S (( O 7 Tesla EV charging in Garage r LG c� ( e-1416ate Contract I hereby:affirm that I n 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: $1550 erformance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance, as provided for by ection 3700 of the Labor Code, for the performance of the work for which this APN Number: 37518015.00 Occupancy T p y yPe� permit is issued. APPLICANT CERTIFICATION 1 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 WIT�IIN 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 •—tJCJ�-r' `V ��• granting of this permit. Additionally, the applicant understands and will comply Issued b �l . -�/ y: Date: with non -point source regulations per the Cupertino Municipal Code, Section 9.18. ature Date/6 b—j RE -ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is ca.3 ►-3V .hC, 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) 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 declarations: Health & Safety Code, Section 25532(x) 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 ections , 25533, and 25534. Section 3700 of the Labor Code, for the performance of the work for which this Owner or author' '�� Date:�v S permit is issued. 1 certify that in the performance of the work for which this permit is issued, I shall �1- ► o`'' y ' �. t s % , / 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 indemnify and keep harmless the City of Cupertino against liabilities, judgments, ARCHITECT'S DECLARATION costs, and expenses which may accrue against said City in consequence of the I 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. Signature Date CUPERTINO ALTERNATIVE ENERGY PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 151OQ9q I (408) 777-3228 • FAX (408) 777-3333 • building(d1cupertino.org 6 AE PROJECT ADDRESS t O �` PI r- APN # 2 1�5 OWNER NAME 'T. _q 4 � � PHONE/;fb E-MAIL AI S � .`1 �•��V�'llL.l STREET ADDRESS (�3 D Li `� �. V CITY, STATE, ZIP �� _r.1 0,0 FAX CONTACT NAME(��-. J �(L P ONE 7.S�-�- s O E-MAIL ICU - h ►'�,d til 17 STREET ADDRESS �7n•l/�-�U (Avco. CITY, STATE ZIP ��51 �1S�a� FAX ,> ❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT XCONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NA $ �CS LICEN NUMBER LI1NSE TYPE JJ BUS. LIC # C , W tS Z COMPANY NAME I E-MAIL � � _ 1 u�� LC h 5— eLIE<Oi A�1'lah�k ("A-6 I FAX STREET ADDRESS CITY, STATE, ZIP C F1 I -) C_:) < .4v -4 F_ , CA 9_51 d�_�s ONE Ll ARCHI I ECT/ENGINEER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF :KSFD or Duplex ❑ Multi -Family PROJECT IN WILDLAND PROJECT IN STRUCTURE: ❑ Commercial URBAN INTERFACE AREA ❑ Yes -;K No FLOOD ZONE ❑ Yes YNo ❑ SOLAR PANELS ELECTRIC VEHICLE CHARGING STATION ❑ SOLAR WATER HEATING ❑ OTHER: FOR SOLAR PANELS: NUMBER OF PANELS/UNITS: KILOWATTS (COMMERCIAL ONLY): TOTAL qVALUATI/� 9 O DESCRIPTION OF WORK o IE V ti RECEIVED BY: LO f LLi 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 r ting to uildi s ction. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes. Signature ofplicanUAgen Cly A h Date: - SUPPLEMENTAL INFORMATION REQUIRED WVf, Zr7G- OFFICE USE ONLY W a OVER-THE-COUNTER ❑ EXPRESS F U W x ❑ STANDARD U e. ❑ LARGE .- n. ❑ MAJO PVApp 2011.doc revised 03/16/11 CITY OF CUPERTINO �(� N MR7, FEE ESTIMATOR -BUILDING DIVISION ��"�1� 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 addh 7 info. FEE ITEMS (Fee Resolution I1-053 Ef: 7f /1/13 ADDRESS: 10310 Calvert Drive DATE: 10/30/2015 REVIEWED BY: Paul Fee—h. Permit hee: APN: 375 18 015 BP#: *VALUATION: 1$1,550 YPERMIT TYPE: Building Permit PLAN CHECK TYPE: Addition PRIMARY USE: SFD or Duplex Plumb. Insp. fee PENTAMATION PERMIT TYPE: SOLAR -RE WORK Install 1 50 Amp 240v Electrical Circuit for Nema 14-50 outlet with disconnect for Tesla EV charging SCOPE in Garage 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 addh 7 info. FEE ITEMS (Fee Resolution I1-053 Ef: 7f /1/13 Ilech, Plein Check 1,111111b. Piarr R E:lee. Plan Check Fee—h. Permit hee: Fhimb, Fertrrit Fee: Elec. Permit Fee: Other i fech. Insp. Other Plumb Inch, Other Flec. lisp. th?eh. Insp. Fee: Plumb. Insp. fee Elea Insp. Fee 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 addh 7 info. FEE ITEMS (Fee Resolution I1-053 Ef: 7f /1/13 FEEQTY/FEE MISC ITEMS Plan Check Fee: $0.00 1� # $109.00 Alternative Energy System 1CHRGSTA EV Charging Station Suppl. PC Fee: (F) Reg. o OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Feer Reg. OT 0,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Coll.slruclion Zctx: :1 ciministralive Fee: E) Work Without Permit? Yes (F) No $0.00 Advanced Planning Fee. $0.00 Select a Non -Residential Building or Structure i blavel Doeumentulion .Fens: Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $1.50 $109.00 TOTAL FEE: 1 $110.50 Revised: 10/01/2015 a u OFFICE C L -\3<,.)E- C (G,S S 'tr -To �SizS P� � CKED BY DATE PLANNING DEPT CUPERTINO ,�(C.J(< <0,1 pane 1 au) t U C-Arw& rn Pest, )ISO R-Ecp C, I V 1 CU DERTINO Builth g Department Esc I d'�Sc oK oci 3 0 2015 I REVIEW COMPLIANCE edA: � W� F—GG IIIS COMMUNITY PMENT DEPARTMENT SUILDIN IWS jON - CUPERTINO ' I + : ;a 2f UST be kept at the Is unlawful to make any _,ame, or to deviate m the Building Official. :�ecifications SHALL NOT --oval of the violation —0) w U —�� i l IVJ� I' G ---��) C -01A& 't IIIS COMMUNITY PMENT DEPARTMENT SUILDIN IWS jON - CUPERTINO ' I + : ;a 2f UST be kept at the Is unlawful to make any _,ame, or to deviate m the Building Official. :�ecifications SHALL NOT --oval of the violation :As Q JNVlldwoo 000 doi o'3MIA33 1 sioz 0 € 130 F t juawpladao BUIp11119 �: ? s'o<�->H '*:Pln -a'r� I j 0 -IcWU 0', S i'P avAvo9 Anthony Lewis Inc. Building and Electrical RESIDENTIAL ELECTRICAL LOAD CALCULATION SHEET Load Calculation for Existing Dwelling Unit 220.83 1. GENERAL LIGHTING: Table 220.12 —1je-7;�Mj Sq. ft. x 3 VA = ----------`y VA Small Appliances: 210.11 (C) (1) and (C) (2) kISOO VA x '-A- circuits=--- '�OQQVA Laundry: 220.52 (B) l `SOO VA x 1 circuit = SOS VA Total: �` 1 VA 2. FIXED APPLIANCES: 220.83 The name plate rating of the following: A. All appliances that are fastened in place, permanently connected, or located to be on a specific circuit. Dishwasher = 1 S 0 0 (1500) VA Disposer = "goo (800) VA Compactor = (99) VA Microwave = �� (1300) VA Spa/Pool Motor = (12,000) VA Attic Fan = (1600) VA Total_ W VA B. COOKING EQu1PMENT: Table 220.55; Notes Col A VA x % = VA 1111) Col B VA x % = VA Col _VAx %= VA Total --------------------------- VA C. DRYER: 220.54; Table 220.54 �{SVO VA LuQ) %=L(S60 VA D. WATER HEATER: CUPERTING —VA Building Department a (� otal----------------------- V1 vs- VA ry OCT 3 0 2015 REVIEVNED FOR CODE COMPLIANCE Rnzvie,rred By: TRJOI (L4 1 Anthony Lewis Inc., Building and Electrical 3. APPLYING DEMAND FACTORS: Table 220.83 (A) or (B) 1" 8000 VA x 100°/, _VA _____________��U Remaining�Z�S O VA x 40% V3 VA Total ------------------------` VA A/C UNIT 1=45400_VA x 100%=_S l-00 VA A/C UNIT 2_ lv_VA x 100% _�� l VA �� EVSE__ W -- -VA x100%=_ w�VA Total ------------------------- l� �q()VA Total of A/C Loads and All Other Loads: 3 VA 4. ELECTRICAL SERVICE: Total VA VA/240 volts = 7) VA l ✓ ` Amps Minimum Conductor size —3 1 b copper „ fir U 1 E' `T'NO Building oepetment OCT 302015 RE VIEWED FOR CODE COMPLIANCE Reviewed BY: . ra GEC LJ copper 2 Need help finding a qualified electrician, or have questions about home charging installation? Contact Tesla at: Charging Installation@teslamotors.com or 1-877-798-3752 INSTALLING YOUR 240 VOLT OUTLET Every Model S includes the Mobile Connector, which is a 20 -foot long cable with a set of adapters for standard electrical outlets. The NEMA 14-50 adapter ensures the best charging experience With the Mobile Connector. Tesla recommends installing a 240 Volt outlet with a NEMA 14-50 receptacle where you plan to park your vehicle. This is a common outlet, often used for home appliances, and the electrician you hire for the installation will provide all necessary materials. You can charge your Model S from this outlet at a rate of 29 miles per hour. Below you Will find all relevant information required for an electrician to complete the installation. Note: municipal building departments frequently require a permit and inspection for any electrical modifications in your home. Any licensed electrician will be able to take care of this paperwork and provide a copy for your records. DETAILS • Voltage: Single phase, 208-250 Volt AC supply, 60 Hertz • Current: 50 Amp circuit breaker / 40 Amp continuous current Wiring Recommendation: 6 American Wire Gauge, copper conductors only • Ground Fault Circuit Interrupter: Not required Service Disconnect: Not required • Receptacle Recommendation: High quality, industrial grade receptacle • Location: Install near vehicle charge port, maximum 15 feet away. Minimum 18 inches above ground. • Electric Code Compliance: Installing electrician will source permit and inspection as required by local municipal building department RECOMMENDED OUTLET LOCATIONS ONE OR TWO VEHICLE GARAGE n n + CU IN FOR YOUR RECORDS ELECTRICAL COMPANY PHONE NUMBER EMAIL ADDRESS ................. • CHARGE PORT PERMIT NUMBER ...................... .......... ' CT 1 O 5 , OUTLETS ItINSTALLATION DATE ODE COMPLIANCE . ewed BT T = 5 L r -i 3500 Deer Creek, Palo Alto, CA 94304 1 Nov. 2014 1 Version 1.0 CUPERTI O 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 o building(a.cupertino.org Owner Name =��5 U ty Permit No.COY/ 6a I Address --- 31 t> (�Ac 6Er 0)�I 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. RMNo 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. 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. _'J�d No 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. X 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.. 5. Please check ONE of the following: 1 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 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 Daae. Owner or Owner Agent's Signafu�� Date'.`�P{1 �) Upon completing and signing this Cc r ' ica e, please return it to the Building Division in order to final your building permit. SB407 2015.doc revised 08/26/15 BUILD -TNG PER11'HT CANNOT BE FI'ALED: AIVD COiVIPLETED U'*N7 -.. THIS CERTIF-cr-TE .-IAS BEEF STCN—�n AlD RETURI ED TSO THEE. UiLT�31�'G DI�,'3SI0�1 1. If the existing plumbing fixture water usage/flow rate is equal to or lower than the figure shown, it is not required to be upgrade . SB407 2015.dac revised 08/26/15 Non -Compliant Water -Conserving Plumbing Fixture Plumbing Fixture (Fixture Complying with Current Code Applicable to New Construction) Maximum !!slater Usa a/Flow Rate ' • Fixture Type 2013 CPC Ch. 4 2013 CPC Ch. 4 2013 CPC Ch. 4 Water Usage 2013 CALGreen Div. 4.3 2013 CALGreen Div. 4.3 2013 CALGreen Div. 5.3 /Flow Rate 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, average flush volume of two reduced flushes and one full flush Urinals Exceed 1.0 0.5 gallons/flush 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 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 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. d 1. If the existing plumbing fixture water usage/flow rate is equal to or lower than the figure shown, it is not required to be upgrade . SB407 2015.dac revised 08/26/15 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(a)cupertino.org S / ss (o v10 CAWS 2/T, 1 V tF- PERMIT CANNOT BE 1FINALED AN C011'II'LETEll UNTIL THIS CERTIFICATE HAS BEEN SGNTE AND RET 1) 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 sr Agent,s,)-Name: to comply with the terms and conditions of this statement Cbjj[r%t_o •Nam �� .... .. ....... ......... ............................................................, ................... .qllrlr,,,,. �...(c�IS -t r'JC. 0 _ 1. ......1_ �0A_ .4 __4 Date:�L� s Si Wit. e. !. Smoke and CO form.doc remised 03/18/14