B-2016-2250CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS:
22140 HIBISCUS DR CUPERTINO, CA 95014-0109 (326 02 026)
OWNER'S NAME: TAMMANA SURESH RAO AND SUBHA PRADA TRUSTEE
OWNER'S PHONE: 408-204-1330
LICENSED CONTRACTOR'S DECLARATION
License Class Lic. #
Contractor HOMEOWNER BUILDER 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:
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.
z. 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 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, 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 4/5/2017
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons:
1. 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 construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three 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.
z. 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.
s. 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 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.
i
APPLICANT CERTIFICATION
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, costs, and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally, the applicant understands
and will comply wi h all non -point source regulations per the Cupertino Municipal
Code, Section 9. f)�.All
Date 4!5/2017
CONTRACTOR: I PERMIT NO: B-2016-2250
ISSUED: 02/17/2017
PHONE NO:
BUILDING PERMIT INFO:
X BLDG —ELECT —PLUMB
_ MECII X RESIDENTIAL _ COMMERCIAL
JOB DESCRIPTION:
.00M AND BATHROOM ADDITION (201 S.F.); ADD (N)
'ER CLOSET IN MASTER BEDROOM (64 S.F.); ADD (N
WAY TO ADDITION (66 S.F.); REMOVE 1/2 BATHROOM FROM
REV #1 - EXTEND BEDROOM (10 S.F.) - ISSUED 4/5/2017
Sq. Ft Floor Area: 201
Valuation: $60000.00
APN Number:
Occupancy Type:
326 02 026
Deferred Submittal (R -3),R-3 (Custom)
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by: ABBY AYENDE
Date: 02/17/2017
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 ofApplicant:
Date: 4/5/2017
ROOF COVERINGS TO BE CLASS "A"
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(a) should I store or handle hazardous
material. Additionally, should I 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 Health & Safety Code ectio s 05, 25533, aud25534.
J
Owner or authorized agent:
Date: 4/5/2017
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 Address
ARC HITE T'S DECLARATION
I understand my plans shall be used as public records.
Licensed
Professional
CUPERTINO
7 K7pw, rnv` RT r
(0
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 950114-3255
(408) 777-3228 - FAX (408) T77-3333 - build in g6d�gu gerflng.C�g
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STREETADDRESS
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STREET ADDRESS,
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OWNER 13 O';QTR-B=ZR El 0'WNTERAGENT 13 CONTRACTOR 1JCONTP-1,CTORAGEN7 ❑ AaCH17ECT 0 E-Q1G--11\ZITR 11 DEVELOPER ❑ TENANT
CON-114CTOR\AME LICENSEYUMBER LJCExSET-i-PE
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kD111111? PS
PRF 42PLICATION rl YES IF YES, PROVIDE COPY OF
&IOM PLANNRNG APPROVAL LETTER
IS THE BLDGAN' n YES
EICHLERROINIE? �.KO
Q ED BYTOTALVALUATION:
By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the properly owner's behalf. I have read chis
application and the information I have provided is correct. l have read the Description ofWork- and verify it is accurate. 1 agree to comply with all applicable local
LTIO .
auth so S nt2tiv Ic upei-t . f enter the above -identified property for inspection purposes.
ordinances and state laws relating to building construction. 11 0
Signature ofApplicant /.A. Date; --,
SL01— 7
SUPPLE1\6ENTAL INFORIMArON RQU=D
I. SLIP
R
-TER
p
8
New SFD or -Multifarnily dwellings: Apply Tor demolition pernait for
existing building(s). Demolition permit is required prior to issuance of building
penlit for new building..
h
LAN RENTIE---
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
-§TX'\
E3
form if any Hazardous'-Vipterials are being used as part of this project.
j
El.FARE
Copy of Planning -�Ipproval Letter or Nie --tin.- with Planning prior to
submittal of Building Permit application.
MR.
6 -TALHFALTH---5
Bld.a.Xpp-2011.doc revised 06121/11
all
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2016-2250
22140 HIBISCUS DR CUPERTINO, CA 95014-0109 (326 02 026) OWNER BUILDER
OWNER'S NAME: TAMMANA SURESH RAO AND SUBHA PRADA TRUSTEE
OWNER'S PHONE: 408-204-1330
LICENSED CONTRACTOR'S DECLARATION
License Class Lic. #
Contractor OWNER BUILDER 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:
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.
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 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, 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 2.17.17
DATE ISSUED: 02/17/2017
PHONENO:
PERNUT INFO:
X BLDG —ELECT _ PLUMB
_ MECH X RESIDENTIAL _ COMMERCIAL
JOB DESCRIPTION:
BEDROOM AND BATHROOM ADDITION (201 S.F.); ADD (N)
MASTER CLOSET IN MASTER BEDROOM (64 S.F.); ADD (I)
HALLWAY TO ADDITION (66 S.F.); REMOVE 1/2 BATHROOM FROM
BEDROOM
Sq. Ft Floor Area: 201 1 Valuation: $60000.00
APN Number: Occupancy Type:
326 02 026 R-3 (Custom)
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by: SEAN HATCH
Date: 02/17/2017
hereby affirm that I am exempt from the Contractor's License Law for one of the RE -ROOFS:
)flowing two reasons: All roofs shall be inspected prior to any roofing material being installed. If a roof is
1. I, as owner of the property, or my employees with wages as their sole installed without first obtaining an inspection, I agree to remove all new materials for
compensation, will do the work, and the structure is not intended or offered for inspection.
sale (Sec.7044, Business & Professions Code)
2. I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three 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.
2. 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.
r) 3. 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 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. 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 regulations per the Cupertino Municipal
Code, Section 9A18.
Signature_)
Signature of Applicant:
Date: 2.17.17
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(a) should I store or handle hazardous
material. Additionally, should I 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 Cup,, Municipal Code, Chapter 9.12 and
the Health & Safety Code, S o s X5505, 25533; and 25534.
Owner or authorized agent:
Date: 2,17 17
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 Address
ARCHITECT'S DECLARATION
understand my plans shall be used as public records.
Licensed
Date.217.17 professional
- CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPAR',. .."NT . BUILDING DIVISION
'10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
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1_1W.
17P EiTti�it (40#8)) J777-3228 • FAX (4108) 777••3333 btlild�i-nryg_(cacupertino.orp
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OWNERNAME 5146 of I nm"00Z.
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CONTRACTOR NAME
LICENSE NUMBER
LICENSB TYPB
BUS. LIC #
COMPANY NAME
E-MAIL
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ARCHITECTIBNGINEER NAME
LICENSE NUMBER
BUS. LIC #
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TOTAL DECKMORCII AREA GARAGE AREA: ❑ DETAC[I
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#DWELLINGUNITS:•
ISASECONDUNIT ❑YES
BEINGADDEW �NQ
SECONDSTORY ]YES
ADDITION? NO
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f
PRE -APPLICATION ❑ YES IF YBs, PROVIDE COPY OF
_
IS THE BLDG AN ❑ YES
RECEI - - - - _ : -
- 1.01 -AL VALUATION:
PLANNINO APPL # ❑ NO PLANNING APPROVAL LETTER
EICIiLER HOME? ❑ NO
_
By my signature below, I certify to each of the following: I ain the property owner or autholizedl,gp f act the property owner's bebalf. I have read this
application and the information I have provided is correct, I have read the Description of Work an&verify it is actuate. I agree to comply with all applicable local
ordinances and state laws relating t br ding eo duction. 1 authorize Teprescntatives of Cupertino to enter the above -identified property for inspection purposes.
Signature of ApplicantlA(9-4-ageut Date:
SUPPLBMI3 AL INh I ATION REQUIRED
; -_'';: °._ .::::.:,:_ ::::_ ; :: ;'.-::; _ =_:.:
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New SFD or Multlfatntly dwellings: Appy 1?
. issuance building
existing building(s). Uc.mohtlQn permit is required prior to Issuance o€ g
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ermit for new building.
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B1dgApp_2011.doc revised 06121111
CUPERTINO
OWNER -BUILDER DISCLOSURE EOR[
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE - CUPERTI NO, CA 95014-3255
(408) 777-3228 - FAX (408) 777-3333 - buildina al )cupertino.org
Dear Property Owner(s):
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified at:
SITE ADDRESS
S � %
APN BP#
OWNER NAM
OWNER ADDRESS
DESCRIPTION OF WORK:
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. I 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. I, 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. I understand building permits are not required to be signed by property owners unless they are responsible for
the construction and are not hiring a licensed Contractor to assume this responsibility.
3. 1 understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may
protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
name instead of my own.
3 4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
5. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be
considered an "employer" under state and federal law.
6. I understand if I am considered an "employer" under state and federal law, I must register with the state and
federal government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to
unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject
me to serious financial risk.
§�_ 7. 1 understand under California Contractors' State License Law, an Owner -Builder who builds single-family
residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by
licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work
is performed under contract with a licensed general building Contractor.
. I understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for
any financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction
defects in the workmanship or materials.
Oiarre7BirilderFonr7 2010.doc revised 04114/10
��
�. 2��_g. | understand | may obtain more information regarding my obligations as an employer fr m the Internal
Revenue Service, the United States Small Business Administration, the California Department of Benefit Payments,
' andtheCahbnn\aDkisionof|ndustdo\Accdents.\sdmzunderstend\maycont uttheCa\UonniaContreutmra'Stoto
License Board (CSLB) at 1-800-321 -CSLB (2752) or www.csib.ca.gov for more information about licensed
.
contractors.
1O.|amaware ofand consent toanOwner-Builder building permit applied for inmyname, and understand that |
am the party legally and financially responsible for proposed construction activity at.the site address listed above,
YA, 11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
by all applicable laws and requirements that govern Owner -Builders as well as employers.
neebonot�/the issuer ofthis form {mmodia�|yofany add�ons.de|e�ons,orchanges toany of�e
'
information |have provided on this ferm.Ucensed contractors are regulated bylaws 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 anunlicensed 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 respons ible for verifying whether or not
Ahose Contractors are prope�ly licensed and the status of their workers' Gom pensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS: Please complete the following construction lending agency information.)
| hereby affirm that there isoconstruction lending agency for the performanceofthe work for which, this permit ieissued
(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 cc ptable to the city may be required to be presented when the permit is issued
to verify the property owner's sl�qnatye,
Property owner's Signature: Date: 4:�—'
_______________________________________________________
(NOTE. The following Authorization — -------' Form is required to be completed by the property owner only when designating en
agent ofthe property owner hzapply for aconstruction permit for the .
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 rnyproject.
Scope of Construction Project (or Description of Work):
Project Location orAddress:
Name of Authorized Agent:
Address ofAuthorized Agent
| declare under penalty ufperjury that |umthe property owner for the address listed above and | personally fiUedout 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
Property Owner's Signature:
Date:
Oi4ine7-Bitilde7-Foi-i77-2OlO.doc revised 04114110
SMOKE / CARBON MONOXIDE ALARMS
( OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
- 10300 TORRE AVENUE• CUPERTINO,CA 95014-3255
GUPERTt
(408)777-3228•FAX(408)777-3333• buildina ancupertino.ora
x s3 karma +,3x F 3 a iigi V ra ``6� n ,: r .,
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PURPOSE
This affidavit is a self-certification for
installation of all required Smoke and Carbon Monoxide Alarms for
compliance with 2016 CRC Section R314, R315,2016 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,R315, 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 X X
bedroom(s)—(Smoke alarms shall not be located within 3 feet of bathroom door)
On every level of a dwelling unit including basements and habitable attics 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 specified below have been tested and are operational, as of the
date signed below.
Address: Z) L/ '0 GV_ Pern 2D 1 (g)
Specify Number of'AlArms: #Smoke Alarms: L #Carbon Monoxide Detectors: /
I have read and agree to comply with the terms and conditions of this statement
Owner(or Owner Agents)IV�IameM:..S n n RJ� j V>4�3 J � 1i I A/vA Signature Date:M L 7,/ '"i 7
Contractor Name: , i; ;
Signature Lic.# Date:
Smoke and CO form.doc revised 01/10/2017
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SMOKE / CARBON MONOXIDE ALARMS ,
OWNER CERTIFICATE OF COMPLIANCE 717.77-q-
„4.0-.44;, COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
CUPERTINO 10300 TORRE AVENUE• CUPERTINO,CA 95014-3255
(408)777-3228•FAX(408)777-3333•buildina(a�cupertino.orq
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PURPOSE N 4=zPURPOSE �, M
This affidavit is a self-certification for the installation of all required Smoke and Carbon Monoxide Alarms for
compliance with 2016 CRC Section R314,R315,2016 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 existingidwelling units exceeds
$1000.00, CRC Section R314,R315, 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 X X
bedroom(s)—(Smoke alarms shall not be located within 3 feet of bathroom door)
On every level of a dwelling unit including basements and habitable attics 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, alarms)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 907.2.114 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 specified below have been tested land are operational, as of the
date signed below
Address. ) 4 0 Pernie i . ' ,2 `r
Specify Number of Alarms #Smoke Alarms ri Carbon Monoxide Detectors.
I have read and agree to comply with the terms and conditions of this statement
O
N
wner(or OwnerAgent(s / AAA ),.
Signature . .. r `f, � �/
JJ Date: ....
Contractor Name:
Signature Lic.# Date:
Smoke and COform.doa revised 01/10/2017