B-2016-3270CITY OF CUPERTINO' BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2016-3270
10800 ASHBOURNE CT CUPERTINO, CA 95014-6400 (375 22 092)
AIR QUALITY
HEATING & AIR
CONDITIONING
INCORPORATED
SAN JOSE, CA 95121
i
OWNER'S NAME: LANG RICHARD C AND CHOW LING L
DATE ISSUED: 12/14/2016
OWNER'S PHONE: 408-718-7576
PHONE NO: (408) 920-3910
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERA
1IT INFO:
License Class C20 Lic. #769446
Contractor AIR QUALITY HEATING & AIR CONDITION ING INCORPORATED
X BLDG _ ELE
X MECH X RESIDENTIAL
T _ PLUMB
_ COMMERCIAL
Date 08/30/2017
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
JOB DESCRIPTI
N:
license is in full force and effect.
REPLACE FURNACE,
SAME LOCATION
I hereby affirm under penalty of perjury one of the following two declarations:
1. 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.
52. Lhave 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
Sq. Ft Floor Area
Valuation: $4650.00
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above
APN Number:
Occupancy Type:
information is correct. I agree to comply with all city and county ordinances
375 22 092
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
PERMIT EXPIRES
IF WORK IS NOT STARTED
City of Cupertino against liabilities, judgments; costs, and expenses which
WITHIN 1
0 DAYS OF PERMIT ISSUANCE OR
may accrue against said City in consequence of the granting of this permit.
Additionally, the applicant understands and will comply with all non-point
180 DAYS FROM
LAST CALLED INSPECTION.
source regulations per the C ertino Municipal Code, Section 9.18.
Issued by:
Signature. ' Date 12/14/2016
Date: 12/1
V.
OWNER-
I hereby affirm that I am exempt from the Contractor's License Law for one of the
All roofs shall be ins
RF ROOFS:
pected prior to any roofing material being installed. If a roof is
following two reasons:
installed without first
obtaining an inspection, I agree to remove all new materials for
1. 1, as owner of the property, or my employees with wages as their sole
inspection.
compensation, will do the work, and the structure is not intended or offered for
sale (Sec.7044, Business & Professions'Code)
Signature ofApplican
:
2. I, as owner of the property, am exclusively contracting with licensed
Date: 12/14/2016,
contractors to construct the project(See.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF
COVERINGS TO BE CLASS "A" OR BETTER
1. 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
kUZARDOUS
MATERIALS DISCLOSURE
performance of the work for which this permit is issued.
I have read the ha
ardous materials requirements under Chapter 6.95 of the
2. I have and will maintain Worker's Compensation Insurance, as provided for by
California Health
& Safety Code, Sections 25505, 25533, and 25534. I will
Section 3700 of the Labor Code, for the performance of the work for which this
maintain compliant
a with the Cupertino Municipal Code, Chapter 9.12 and the
permit is issued.
Health & Safety Code,
Section 25532(a) should I store or handle hazardous
3. I certify that in the performance of the work for which this permit is issued, I
material. Additionally,
should I use equipment or devices which emit hazardous
air contaminants as
defined by the Bay Area Air Quality Management District I
shall not employ any person in any manner so as to become subject to the
will maintain compliance
with the Cupertino Municipal Code, Chapter 9.12 and
Worker's Compensation laws of California. If, after making this certificate of
the Health
& Safety CodVons 25505, 25533, and 25534.
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
Owner or authoriz
d agent' ,
be deemed revoked.
Date 12/14/2016
APPLICANT ERTIFICATION
I certify that 1 have read this application and state that the above information is
1 hereby affirm that
here is a co ction I ding agency for the performance
correct. I agree to comply with all city and county ordinances and state laws
of work's for which this
permit is issued (Sec. 3097, Civ C.)
relating to building construction, and hereby authorize representatives of this city
Lender's Name
to enter upon the above mentioned property for inspection purposes. (We) agree
to save indemnify and keep harmless the City of Cupertino against liabilities,
Lender's Address
judgments, costs, and expenses which may accrue against said City in
DECLARATION
consequence of the granting of this permit. Additionally, the applicant understands
I understand my plans
ARCHITECT'S
shall be used as public records.
and will comply with all non-point source regulations per the Cupertino Municipal
Code, Section 9.18.
Licensed
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DI ISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • buildingft—cupertino.ora
C3 - ofi>32' a
3ING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEA
PROJECT ADDRESS;
(D (.—
APN # �
V
— 2 ^J 0'� ZOWNERNAMEii(\\V\
PHONE
E-MAIL
STREET ADDRESS
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CITY, STATE; ZIP
FAX
CONTACT NAMEPHO
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CSS 5�d
& IL
STREET ADDRESS
)
CITY, STATE, ZIP
Sod
7
FAX
❑ OWNER 171 OWNER -BUILDER ❑ OWNERAGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ARCHITECT
❑ ENGINEER. ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME
CA -�
LICENSE NUMBER
q
LIC
SE TYPE
tc�
BUS. LIC #
COMPANYNA V\�
E S Vck��C
�Vl
FAX 400 e (�( "� R
STREET ADDRESSA ` ^
V i Aip
CITY�`T�ATE, Z�
1
l
.
PHONE
ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E -MATT
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
USE OF ❑ SFD or DUPLEX ❑ • MULTI -FAMILY
BUILDING: ❑ COMMERCIAL
-PROJECT IN WILDLAND ❑ S
URBAN INTERFACE AREA
PROJECT IN
FLOOD ZONI
❑ YES
❑ NO
IS THE BLDG AN ❑ YES
EICHLER HOME? ❑ NO
DESCRIPTION OF WORK A n
TOTAL VALUATION: r LS REO BX
By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the ner s behalf. I have read this
application and the information I have provided is co ct. I have read the Description of Work and verify itis accurate. I agree to comply with all applicable local
ordinances and state laws relating to T-W7
on. I authorize representatives of Cupertino to enter the bove-identified property for inspection purposes.
Signature of ApplicanUAgent: Date:
REQUIRED
MEPMisc4pp 2011.doc revised 06/21/11,
f',
CERTIFICATE OF COMPLIANCE CF1R-ALT 02-E
Alterations to Space Conditioning Systems (formerly CF -IR -ALT -HVAC) (Page 1 of 3 )
Project Name: 10800 ASHBORNE CRT Date Prepared: 2016-12-09
A. General Information
MR -ALT -02 is applicable to multiple space conditioning systems contained within a single dwelling unit. When multiple dwelling units must be documented,
use one CFIR-ALT02 document for each dwelling unit.
01
Project Name
10800 ASHBORNE CRT
02
Date Prepared
2016-12-09
03
Project Location
10800 ASHBORNE CRT
04
Bulling Type
Single family
05
CA City
Cupertino
06
Dwelling Unit Name
10800 ASHBORNE CRT
Dwelling Unit Conditioned
#all
07
zip Code
95U14
03
Floor Area (ft2)
ZbU4
SC System
CFA served
stem
ga t
'L.gvNA"TI
Number of space conditioning
1 stagy,
g r
SyNR' U' 'f
09
Climate Zone
4
10
(SC) systems in this dwelling
1
ducted
containing
�..
more than 40
unit.
entirely new
B. Space Conditioning (SC) System`Information° `
atiVAU, Jaw
01
02
`, ' 03
04
06'
07�
0$
09
10
11
OF
C�=�
Is the
#all
A
AW OW
SC System
SC System
CFA served
stem
ga t
'L.gvNA"TI
nstalh ' nevi � C
��g
1 stagy,
g r
SyNR' U' 'f
nsta Ihtg
Yds
. nstalling
Identification or
Location or Area
by this SC
ducted
containing
Cyt
system
more than 40
,d�
entirely new
entirely new
Name
Served
System (ft2)
system?
component?
components?
feet of ducts?
duct system?
SC system?
Alteration Type
System 1
Location 1
2604
Yes
No
Yes
No
No
No
Altered space
conditioning system
C. Extension of Existing Duct System, Greater Than 40 Feet (Section150.2(b)Diib)
This section does not apply to this project.
Registration Number: 216-A0455306A-000000000-0000 Registration Date/Time: 2016-12-09 09:49:17
CA Building Energy. Efficiency Standards 2613 Residential Compliance Report Version: 2013 Rev 1.008
Schema Version: 0.555SDD'
HERS. Provider: CaICERTS
Report Generated: 2016-12-09 09:49:15
CERTIFICATE OF COMPLIANCE CFIR-ALT 02-E
Alterations to Space Conditioning Systems (formerly CF -1R -ALT -HVAC) (Page_2 of 3 )
D. Altered Space Conditioning System (Sections 150.2(b)1E and F)
01
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-11alue
Central gas
All new
Central split
No cooling
This field or
This field or
This field or
This field or
System 1
furnace
heating
AFUE
80
AC
component
section is not
section is not
Setback
section is not
section is not
components
altered
applicable
applicable
applicable
applicable
Reauired,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: < 1591., or:5 10% leakage to outside, or seal all accessible leaks.
CF2R-MCH-25-H & CF3R-MCH-25-H Refrigerant Charge Verificiition required when refrigerant containing components are installed or altereflapplicable in CZ 2, 8-15).
CF2RCF3R-MCH-23 & CF3R-MCH-23 Air Flow X900 CFM%ton required whgn MCH -25 is required. ,
Exceptions:`
previously
Ducts stems registered with HERS provider as reviousl sealed are exe from -20 Duct LItge Tes ' m
Heatin =onl stems and AirHand er Furnace es do not re uire vmpt
g. y systems / R �' 2nficaeof Air FIow�MC3� a ng' nt ha' a
:
H-
-Existing duct systems constructed, insulated or sealedwith as,') s re exem from MC - uL' ge Test
ui
Entirely New or Complete Replacement D
.Baa
E. Ent' with r tho t q ipment n ratSecti s1.2 lilDn sand y1 0.2(b)1E, F)�
uc tem
wr
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: 216-A0455306A-000000000-0000 Registration Date/Time: 2016-12-09 09:49:17 HERS Provider: CalCERTS
CA Building Energy Efficiency Standards - 2013 Residential Compliance Report Version: 2013 Rev 1.008 Report Generated: 2016-12-09 09:49:15
Schema Version: 0.555SDD
a""
;ze
CERTIFICATE OF COMPLIANCE CFIR-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:
McLaughlin, Brianne E
Company;
Signature Date:
The Energuy CA LLC
2016-12-09 09:49:16
Address:
CEA/ HERS Certification Identification (if applicable):
1215 K St., 17th Floor
City/State/Zip: _
Phone:
Sacramento CA 95814
877-600.0123
Responsible Person's Declaration statemen JJ
I certify the following under penalty of perjury, under the laws„# the State of California:
1. The information provided on tliis Certificate of Comri' lance is true and correct.
2. 1 am eligible under Division 3 ofthe Business and Professions Code to accepfi responsibility for the building design or system design identified on this Certificate of Compliance (responsible designer).
3. That the energy features and performance specifications matarrais; co` nents, and anufact red devices for he buildin design o system desi n identified on this Certificate of Compliance conform to the
requirements of Title 24, Part land Pack 6 of the Califani' Lode of ons.
4. The building design features or system design featyres r entified o his Certify f lance ar to the i orm provided o t ca ° pliance documents, worksheets,
`
calculations, plans and specifications subinitteto he orcemen encyfo' �v this buil ng per t a icati
S. I will ensure that a registered copy of this Certifica pliance s lie, _ ail le rtlaW, 4, k 1p p mit( ,issr� for1k it ` 'g, an a,:;,o av b tfr enforcement agency for all applicable
�s. e
inspections. I understand that a regi copy of th dicate of Cnpancrequi d to ljnduded ,l th cum dtio .the ler p vides t tie b ' ing owner at occupancy.
Responsible Designer CN, = .
Respon&le De ig ' r 5r nature: �n
V4
McLaughlin, Brianne E
Company: _
Date Signed:
The Energuy CA LLC
'2016-12-09 09:49:17
Address:
License:
1215 K St., 17th Floor
City/State/Zip:
Phone:
Sacramento CA 95814
877-600-0123
Digitally signed by CaICERTS. This digital signature is provided in order to secure the content of this registered document and in noway implies Registration Provider responsibility for the accuracy of the information.
Registration Number: 216-A0455306A-000000000-0000
CA Building Energy Efficiency Standards - 2013 Residential Compliance
Registration Date/Time: 2016-12-09 09:49:17
Report Version: 2013 Rev 1.008
Schema Version 0.555SDD
HERS Provider: CaICERTS
Report Generated: 2016-12-09 09:49:15
i
i
?-70
CERTIFICATE OF VERIFICATION ! CF3R-MCH-20-H
Duct Leakage Diagnostic Test (Page 1 of 3 )
Project Name: 10800 ASHBORNE CRT Enforcement Agency: City of i Permit Number: PENDING
Cupertino
i
Dwelling Address: 10800 ASHBORNE CRT City: Cupertino Zip Code: 95014
A. System Information
i
i
01
Space Conditioning System Identification or Name
System 1
i
02
Space Conditioning System Location or Area Served
Location 1
03
Building Type from CF -111
Single family
04
Verified Low Leakage Ducts in Conditioned Space
(VLLDCS) Credit from CF1R?
No, credit is not taken
05
Verified Low Leakage Air Handling Unit (VLLAHU) Credit
from CF1R? -
No, credit is not taken
06
Duct System Compliance Category-
Alteration using smoke test
MCH -20e -Sealing AI! Accessible% eaks sing smoW'T t.
B. Duct Leakage Diagnostic Test g�J' V
i
01
Condenser Nominal Cooling Capacity (ton)
0
02
Heating Capacity (kBtu/h)
54
i
03
Conditioned Floor Area served by this HVAC system (ft2)
2604
I
04
Duct Leakage Test Condition
Test final
05
Duct Leakage Test Method
Total leakage
06
Leakage Factor
0.15
07
Air Handling Unit Airflow (AHUAirflow) Determination
Method
Heating system method
08
Measured AHUAirflow
i
This field or section is not applicable
I
09
Calculated Target Allowable Duct Leakage Rate (cfm)
176
10
Actual duct leakage rate from leakage test measurement
(cfm)
700
Registration Number: 216-A0455306A-M2000002A-M20A Registration Date/Time: 2016-12-14,'21:34:15 HERS Provider: CaICERTS
CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.008 Report Generated: 2016-12-14 21:34:13
2013 Residential Compliance Schema Version: 2013.1.007
CERTIFICATE OF VERIFICATION
Duct Leakage Diagnostic Test
CF3R-MCH-20-H
(Page 2 of 3
B. Duct Leakage Diagnostic Test
01
Compliance Statement: System passes using smoke test of an altered HVAC system
duct Smoke is from
in an existing building. No visible smoke
exits the accessible portions of the system. only emanating airlhandling
unit (AHU) cabinet and non
11
accessible portions of the duct system. Note - Accessible is defined as having acce�s
thereto, but which first may require
removal or opening of access panels, doors, or moving similar obstructions. If access
to the ducts requires an object to be
demolished or deconstructed then sealing of those ducts is not required
12
Notes:
C. Additional Requirements for Compliance
01
System was tested in its normal operation condition. No temporary taping allowed!.
for this Certificate of Verification as a whole to be determined to be in compliance.
Outside air (OA)" duct connections to the central forced air duct system shall not b�
sealed/taped off during duct leakage
02
testing. CA ducts used for Central Fan Integrated (CFI) Indoor Air Quality ventilation
systems, or Central Fan Ventilation
1
Cooling Systems, that utili7e dampers that open only when OA is required and automatically
close when CA is not required,
may configure the CA damper to the closed position during duct leakage testing.
03
All supply and return register boots, were sealed to the drywall.
04
Ar
Building cavities were not used as pler ms or r 'r%urns in Wh f,
W 1
05
Ah V�
If cloth backed tape was as cov&bdAAiIthyMasttc and-tif"a ban dA "t
si
06
All connection points between Iffie air handler and the supply',arid return plerams14,
If the system complies using the Smoke Test method, the smoke test was conducted in accordance with the requirements
I
07
of Reference Residential Appendix RA3.1.4.3.6. Systems that comply using smoke ti bst shall not be included in sample
groups for HERS verification compliance.
08
Verification Status:
Pass - all applicable requirements are met
09
Correction Notes for this table:
The responsible persons signature on this compliance document affirms that all applicable requirements in this table have
been met unless otherwise noted in the Verification Status and the Corrections Notes in this table.
I
D. Determination of HERS Verification Compliance
All applicable sections of this document shall indicate compliance with the specified verifilcation
protocol requirements in order
for this Certificate of Verification as a whole to be determined to be in compliance.
01
1 Complies: All specified verification protocol requirements on this document are met.
Registration Number: 216-A0455306A-M2000002A-M20A Registration Date/Time: 2016-12-14121:34:15 HERS Provider: CaICERTS
CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.008 Report Generated: 2016-12-14 21:34:13
2013 Residential Compliance Schema Version: 2013.1.007
CERTIFICATE OF,VERIFICATION
Duct Leakage Diagnostic Test
CF3R-MCH-20-H
(Page 3 of 3 )
Documentation Author's Declaration Statement
i
1.1 certify that this Certificate of Verification documentation is accurate and co'•nplete.
Documentation Author Name:
Documentation Author Signature:
Richard Cunningham
Company:
The Energuy CA LLC
Date Signed:
2016-12-14 21:34:15
Address:
CEA/ HERS Certification Identification
(if applicable):
1215 .K St., 17th Floor
City/State/Zip:
Phone:
Sacramento CA 95814
877-600-0123
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,6n this Certificate of Verification is true and correct.
2. 1 am the certified HERS Rater who performed the verification identified and reported on this Certifi
ate of Verification (responsible rater).
3. The installed features, materials, components, manufactured devices, or system performance diagnostic
results that require HERS verification
identified on this Certificate of Verification comply with,the,applicable requirements in Reference Appendices
RA2, RA3, and the requirements
specified on the Certificate of Compliance foe the building approved by the enforcement agency.
I
4. The information reported on applicable sections of:the Certifica e(s).o ; ristallattIPoriJGF2 "t dr ""
construction or installation conforms to the equiremeats,, eci d n the Ce icate(s f C plia
5. I will ensure thata registered cc of this C ificate of .esi atl n all be po" or vailab
Sub ted by the persvn(s) responsible for the
"e (CX) approved 1Y a em t;agency.
with t e, ilding per'" it "
O issu d r the
building, and made agailabt` to t enforce t a n . fo II pli , lei pest' I nde" and,
Verification is required to bei
ata i ere co PY Q4,th%Cer%ica . of._. .-
with the ocumentation the builder provides to t e building owner
at occupancy.
Builder Or Installer Information As -Shown On -The Certificate"Of Installation
Company Name (Installing Subcontractor, General Contractor, or Builder/Owner):
AIR QUALITY HEATING & AIR CONDITIONING INCORPORATED
Responsible Builder or Installer Name:
CSLB License:
Matt Farber
769446
HERS Provider Data Registry Information
Sample Group Number (if applicable):
Dwelling Test Status in Sample
Group (if applicable)
Tested
HERS Rater Information
I
i
HERS Rater Company Name:
j
The Energuy CA LLC
Responsible Rater Name:
Richard Cunningham
Responsible Rater Signature:)
�V
Responsible Rater Certification Number w/ this HERS Provider:
Date Signed:
CC2005596
2016-12-14 21:34:15
"
Digitally signed by Ca10ERTS. This digital signature is provided in order to secure the content of this registered document, and in noway implies
Registration Provider responsibility for the accuracy of the information.
Registration Number: 216-A0455306A-M2000002A-M20A Registration Date/Time: 2016-12-14;21:34:15 HERS Provider: CaICERTS
I
CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.008 Report Generated: 2016-12-14 21:34:13
2013 Residential Compliance Schema Version: 2013.1.007
SMOKE / CARBON MONOXIDE
OWNER CERTIFICATE OF CON
COMMUNITY DEVELOPMENT DEPARTMENT • BI
CUPERTINO 10300 TORRE AVENUE • CUPERTINO, CA 95014•
(408) 777-3228 • FAX (408) 777-3333 • buildinaCa ct
PURPOSE-
.
This affidavit is a self -certification for the installation of all required Si
compliance with 2013 CRC Section R314, 2013 CBC Sections 420.6 and
inspections are required.
GENERAL INFORMATION
Existing single-family and multi -family dwellings shall be provided
Monoxide alarms. When the valuation of additions, alterations, or r
$1000.00, CRC Section 8314 and CBC Sections 907.2.11.5 and 420.6 rE
Monoxide Alarms be installed in the following locations:
AREA
Outside of each separate sleeping area in the immediate vicinity of
the bedroom(s)
On Bevel of a dwelling unit including basements
Within each sleeping room
LARMS
LIANCE
DING DIVISION
Fil,le
�'ISIt3N
e and Carbon Monoxide Alarms for
.2.11.2 where no interior access for
Smoke Alarms and Carbon
to existing dwelling units exceeds
that Smoke Alarms and/or Carbon
i ALARM CO ALARM
X X
X X
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, alarr (s) may be solely battery operated.
In existing dwelling units, alarms are permitted to be solely battery operafed where repairs or alterations do
not result in the removal of wall and ceiling finishes or there is no access ley means of attic, basement or crawl
space. Refer to CRC Section R314 and CSC Sections 907.2.11.4 and 420.6.2.+1 An electrical permit is required for
alarms which must be connected to the building wiring.
As owner of the above-referencedro er I hereby certify that the alarms) referenced above has/have been
p p �'.
installed in accordance with the manufacturer's instructions and in compl'lance with the California Building
and California Residential Codes. The alarms specified below have been t sted and are operational, as of the
date signed below.
Address: to A00 -,It Lou,,_r4-
Specify Number of Alarms:
I have read and a ree to COMM/
ier (orOwner Agents ,Name:
Signature ... . ......
tt`" ,tier, Permit No. 8--2-016-°3Z?D
J�
M- 4 Carbon Monoxide Detectors: r
e terml and conditions of this statement
::....... ...................................... Date: #2 ® �
Signature............................................................... Lic.# .............
Date;
Smoke and CO form.doc revised 09/27/16
SMOKE / CARBON MONOXIDE ALARMS
OWNER CERTIFICATE OF COMOLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION F LE
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 d ?'
(408) 777-3228 • FAX (408) 777-3333 • building(aDcuilrtino.ora
PERMIT CANNOT BEFINALED UNTIL THIS CERY
COMPLETED, SLgAo AND RE r TRNEp To THE B
PURPOSE
This affidavit is a self -certification for the installation of all required Sir
compliance with 2013 CRC Section R314, 2013 CSC Sections 420.6 and
inspections are required.
"ATE HAS BEEN
,DING DIVISION
e and Carbon Monoxide Alarms for
.2.11.2 where no interior access for
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
Signature
ISMOKE ALARM
CO ALARM
Outside of each separate sleeping area in the immediate vicinity of
the bedroom(s)
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X
X
On every level of a dwelling unit including basements
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X
Within each sleeping room
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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 alarT(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 specified below have been (tested and are operational, as of the
date signed below.
Address: 0 I nc% 414 v 0 %�
Specify Number of Alarms:
# Smoke Alarms:
Permit No. a ®2D (6-3210
1 Monoxide Detectors:
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Owner or Owner Agent's) Name:
Signature
Date: �
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Contractor Name:
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Signature............................................................ .
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1..... Lic.# ......................................Date:
Smoke and COJbM.doc revised 09127116