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15020142CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10779 BROOKWELL DR CONTRACTOR: VALENTINE PERMIT NO: 15020142 CORPORATION OWNER'S NAME: LI-ERH WANG I I I PELICAN WAY DATE ISSUED: 02/25/2015 OWNER'S PHONE: 4086918458 SAN RAFAEL, CA 94901 PHONE NO: (415)453-3732 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑ License Class VOLUNTARY FOUNDATION REPAIR "i;AoC Z Contractor CDate I hereby affirm that I am licensed under a 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: $39195 performance of the work for which this permit is issued. ave and will maintain Worker's Compensation Insurance, as provided for by tLoetion 3700 of the Labor Code, for the performance of the work for which this APN Number: 36921013.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct. 1 agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save 180 DAYS O 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 granting of this p it. Additionally, the applicant understands and will comply Issued by: Date: with all non-po' source regulations per the Cupertino Municipal Code, Section 9.18. �S RE-ROOFS: Signature Date All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, 1 agree to remove all new materials for inspection. ❑ OWNER-BUILDER DECLARATION Signature of Applicant: Date: I 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(a) should I store or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally, should I use equipment or devices which emit hazardous Compensation, as provided for by Section 3700 of the Labor Code, for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with th upertino Municipal Code, Chapter 9.12 and 1 have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Sect' 25 553 Section 3700 of the Labor Code, for the performance of the work for which this - Owner authorized Date: permit is issued. or agefRUCTION 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 CON 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. 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, 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 r CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 y� CUPERTINO (408) 777-3228 • FAX (408) 777-3333 • buildin cu ertino.or �}JGi NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION i TI ❑ REVISIION /DEFERRED / ORIGINAL PERMIT # PRO :(,r nf/�D ! APN a 12 J„/% l,/ OW R�NsiM P / /3 f.MAIL /� S"rRE QcQ� vG' .� U CITY, (ixTQIP V /Jc FAX CONTACT NAME PHONE E-MAIL /Setu STREET f C rv,STATE, ZIP'S . _ / FAX ❑ OWNER ❑ OWNER-HUILDFR ❑ OWNER AGI:AT u CO3fRACTOR OCO(NTRACI-ORAGFNT 11❑ ARCIIITFCT PNGINFFR 11 DEVELOPER ❑ TENANT C A NA I " L L[ SI E#511� BUS LIC k \ l ILA Cf a ! „� C FAX STR "E?1A DRC STATE, Z1P PLR N j y , ARCH-.CT/ENGINGF&,NAM E,/ LICjt�JSE P BUS, f ICk CO7C>)N AMB �� E: MAIL FAX STRE DD E C Y: SZrf,.ZIP ! ., (y� / Y 1l". G�/' PHONE �� (•� T T —ikl t �j/��,/ DESCRIPTION OF WORK 1 ,) ,�j t! EXISTING USE PROPOSED USE CONSTR TYPE N STORIFS USE TYPE OCC. SQ.FT, VALUATION (S) F,XISTG NEW FLOOR UPMO IOTAI AREA ARFA ARFA NFT ARFA BATHROOM KITCHEN OTHER REMODEL AREA REMODELAREA RFMOUL'L AREA PORCH AREA1[)]-,('KARI-.A�ITOl'Al.[)I-CKI'ORCIIAI�l�A GARAGEAREA. DETACH ❑ATIACH N DWELLING UNITS'. CONDUNIT ❑YFS SECOND SEORY ❑YI-.S ADDED? ❑NO ADDIIION? El NO PRF. -APPLICATION E] YES 11 YES, PROVIDF.COPY 01- ISIlit HLDGAN ❑ YES CEIVED Y: LI;ATION: PLANNINGAPPLu E] NO PLANN ING APPROVAL LETT ER NICHLh:R HOME? �NO r 1.fALV By my signature below, I certify to each of the following: I am the property owner or authorized agent to the property owner's behalf. I have4read this application and the information I have p (vide 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 b ding �1`1. R1 a 1 'utho ` zerepresentatives of Cupertino to enter the above-identif icd property f�pspection purposes. Signature ApplieandAgent Date: � of _ _ _,7, SUPPLEMENT L 1NFOR TIONUIRED PLAN CHECK TYPE ROUTING SLIP ❑ OVER-THE-COUNTER ❑ BUILDING PLAN REVIEW New SFD or Multifamily dwellings: Apply for emolition permit for existing building(s). Dernolition permit is required prior to issuance of building permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUBHC WORKS __ form if any Hazardous Materials are being used as part of this project. ❑ ❑ LARCH: FIRE DEPT Copy of Planning Approval Letter or Meeting with Planning prior to El El SANITARYDISTRICT submittal Of Building Permit application. MAJOR SEWER ❑ ENVIRONMENTAL HEALTH BldgApp_2011.dnc revised 06/21/11 CITY OF CUPERTINO ww FEE ESTIMATOR — BUILDING DIVISION imADDRESS: 10779 brookwell dr DATE: 02/25/2015 REVIEWED BY: Mendez APN: BP#: VALUATION: 1$39,195 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex USE: F 0.0 PENTAMATION 1GENRES PERMIT TYPE: WORK foundation repair SCOPE NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School Dictrirt otr. L Thevo foov oro havod on tho nroliminary information ovailahle and are only an estimate Contact the Dent for addn'I info. FEE ITEMS (Fee Resolution 1I-053 Ejf.' 7/1/13) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 1 # $859.00 Foundation Repair IFOUNDREPA Suppl. PC Fee: Q Reg. Q OT F 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee:Q Reg. Q OT F0.0 T hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Work Without Permit? 0 Yes Q No $0.00 Advanced Planning Fee: $0.00 Select a Non -Residential Building or Structure A - Strong Motion Fee: IBSEISMICR $5.10 Select an Administrative Item 1 Bldg Stds Commission Fee: IBCBSC $2.001 SUBTOTALS: $7.10 $859.00 TOTAL FEE: $866.10 Revised: 02/14/2015 CUPERTINO Owner Name Address kb 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(cDcugertino.org Permit No. 1)r, CA gSviP� PERMIT CANNOT BE FINALED AND COMPLETED UNTIL THIS CERTIFICATE HAS BEEN SIGNED AND RETURNED , THE BUILDINIs DIVISION . Please refer to the attached California Civil Code Sections 1101.1 — 1101.8 which are part of this Certification form. 1. Is your real property a registered historical site? ❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Sign below and skip the rest of the form. Owner' Signature: rG L- - Date: _�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. Sign below and skip the rest of the form. Owner' Signature: _ C"4,(. t.. .-- Date: -No Go to Question 3. 3. Is water service permanently disconnected for your building? ❑ Yes Civil Code Sections 110 1. 1 through 1101.8 do not apply. Sign below and skip the rest of the form. Owner' Signature: , , (.- 1 �.�. ... Date: Nr 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 110 1. 1 through 1101.8 do not apply. Sign below and skip the rest of the form. Owner' Signature: Date: 31.> S /is Yes 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. Refer to the attached. V/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. SB407 2014.doc revised 03/18/14 ore January 1, 2019, all non-compliant plumbing fixtures shall be replaced with water- conserving W fixtures throughout the building (regardless of whether property undergoes alterations or 11 0 nts). I/We, the owner(s) of this property, certify under penalty of perjury that non-compliant plumbing fixtures have been replaced 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 below. Owner's (or Owner Agent's) Signature: ; ^�� Vim ` ---r Date: Upon completing and signing this Certificate, please return it to the Building D?vision in order to final your permit. 1. If the existing plumbing fixture water usage/flow rate is equal to or lower than the figure sbown, it is not required to be upgraded. SB407 2014. doe revised 03/18/14 Non -Compliant Water -Conserving Plumbing Fixture Plumbing Fixture (Fixture Complying with Current Code Applicable to New Construction) Maximum Water Usage/Flow Rate Fixture Type Water Usage 2013 CPC Ch. 4 2013 CPC Ch. 4 2013 CPC Ch. 4 !Flow Rate 2013 CALGreen Div. 4.3 2013 CALGreen Div. 4.3 2013 CALGreen Div. 5.3 Single -Family Multi -Family Commercial Residential Residential Water Closets Exceed 1.6 Single flush toilets: 1.28 gallons/flush (Toilets) Gallons/flush Dual flush toilets: 1.28 gallons/flush effective flush volume (the composite, 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. 1. If the existing plumbing fixture water usage/flow rate is equal to or lower than the figure sbown, it is not required to be upgraded. SB407 2014. doe revised 03/18/14 ma— CALIFORNIA CIVIL CODE SECTIONS 1101.1-1101.8 Civil Code Division 2. Property Part 4. Acquisition of Property Title 4. Transfer Chapter 2. Transfer of Real Property Article 1.4. Installation of Water Use Efficiency Improvements ........ 1101.1 — 1101.8 1101.1. The Legislature finds and declares all of the following: (a) Adequate water supply reliability for all uses is essential to the future economic and environmental health of California. (b) Environmentally sound strategies to meet future water supply and wastewater treatment needs are key to protecting and restoring aquatic resources in California. (c) There is a pressing need to address water supply reliability issues raised by growing urban areas. (d) Economic analysis by urban water agencies has identified urban water conservation as a cost-effective approach to addressing water supply needs. (e) There are many water conservation practices that produce significant energy and other resource savings that should be encouraged as a matter of state policy. (f) Since the 1991 signing of the "Memorandum of Understanding Regarding Urban Water Conservation in California," many urban water and wastewater treatment agencies have gained valuable experience that can be applied to produce significant statewide savings of water, energy, and associated infrastructure costs. This experience indicates a need to regularly revise and update water conservation methodologies and practices. (g) To address these concerns, it is the intent of the Legislature to require that residential and commercial real property built and available for use or occupancy on or before January 1, 1994, be equipped with water -conserving plumbing fixtures. (h) It is further the intent of the Legislature that retail water suppliers are encouraged to provide incentives, financing mechanisms, and funding to assist property owners with these retrofit obligations. 1101.2. Except as provided in Section 1101.7, this article shall apply to residential and commercial real property built and available for use on or before January 1, 1994. 1101.3. For the purposes of this article: (a) "Commercial real property" means any real property that is improved with, or consisting of, a building that is intended for commercial use, including hotels and motels, that is not a single-family residential real property or a multifamily residential real property. (b) "Multifamily residential real property" means any real property that is improved with, or consisting of, a building containing more than one unit that is intended for human habitation, or any mixed residential -commercial buildings or portions thereof that are intended for human habitation. Multifamily residential real property includes residential hotels but does not include hotels and motels that are not residential hotels. (c) 'Noncompliant plumbing fixture" means any of the following: (1) Any toilet manufactured to use more than 1.6 gallons of water per flush. (2) Any urinal manufactured to use more than one gallon of water per flush. (3) Any showerhead manufactured to have a flow capacity of more than 2.5 gallons of water per minute. (4) Any interior faucet that emits more than 2.2 gallons of water per minute. (d) "Single-family residential real property" means any real property that is improved with, or consisting of, a building containing not more than one unit that is intended for human habitation. (e) "Water -conserving plumbing fixture" means any fixture that is in compliance with current building standards applicable to a newly constructed real property of the same type. (f) "Sale or transfer" means the sale or transfer of an entire real property estate or the fee interest in that real property estate and does not include the sale or transfer of a partial interest, including a leasehold. 1101.4. (a) On and after January 1, 2014, for all building alterations or improvements to single-family residential real property, as a condition for issuance of a certificate of final completion and occupancy or final permit approval by the local building department, the permit applicant shall replace all noncompliant plumbing fixtures with water - conserving plumbing fixtures. (b) On or before January 1, 2017, noncompliant plumbing fixtures in any single-family residential real property shall be replaced by the property owner with water -conserving plumbing fixtures. (c) On and after January 1, 2017, a seller or transferor of single-family residential real property shall disclose in writing to the prospective purchaser or transferee the requirements of subdivision (b) and whether the real property includes any noncompliant plumbing fixtures. 1101.5. (a) On or before January 1, 2019, all noncompliant plumbing fixtures in any multifamily residential real property and in any commercial real property shall be replaced with water -conserving plumbing fixtures. (b) An owner or the owner's agent may enter the owner's property for the purpose of installing, repairing, testing, and maintaining water -conserving plumbing fixtures required by this section,- consistent with notice requirements of Section 1954. (c) On and after January 1, 2019, the water -conserving plumbing fixtures required by this section shall be operating at the manufacturer's rated water consumption at the time that the tenant takes possession. A tenant shall be responsible for notifying the owner or owner's agent if the tenant becomes aware that a water -conserving plumbing fixture within his or her unit is not operating at the manufacturer's rated water consumption. The owner or owner's agent shall correct an inoperability in a water -conserving plumbing fixture upon notice by the tenant or if detected by the owner or the owner's agent. (d) (1) On and after January 1, 2014, all noncompliant plumbing fixtures in any multifamily residential real property and any commercial real property shall be replaced with water -conserving plumbing fixtures in the following circumstances: (A) For building additions in which the sum of concurrent building permits by the same permit applicant would increase the floor area of the space in a building by more than 10 percent, the building permit applicant shall replace all noncompliant plumbing fixtures in the building. (B) For building alterations or improvements in which the total construction cost estimated in the building permit is greater than one hundred fifty thousand dollars ($150,000), the building permit applicant shall replace all noncompliant plumbing fixtures that service the specific area of the improvement. (C) Notwithstanding subparagraph (A) or (B), for any alterations or improvements to a room in a building that require a building permit and that room contains any noncompliant plumbing fixtures, the building permit applicant shall replace all noncompliant plumbing fixtures in that room. (2) Replacement of all noncompliant plumbing fixtures with water -conserving plumbing fixtures, as described in paragraph (1), shall be a condition for issuance of a certificate of final completion and occupancy or final permit approval by the local building department. (e) On and after January 1, 2019, a seller or transferor of multifamily residential real property or of commercial real property shall disclose to the prospective purchaser or transferee, in writing, the requirements of subdivision (a) and whether the property includes any noncompliant plumbing fixtures. This disclosure may be included in other transactional documents. 1101.6. The duty of an owner or building permit applicant to comply with the requirements of this article shall be postponed for one year from the date of issuance of a demolition permit for the building. If the building is demolished within the one-year postponement, the requirements of this article shall not apply. If the building is not demolished after the expiration of one year, the provisions of this article shall apply, subject to appeal to the local building department, even though the demolition permit is still in effect or a new demolition permit has been issued. 1101.7. This article shall not apply to any of the following: (a) Registered historical sites. (b) Real property for which a licensed plumber certifies that, due to the age or configuration of the property or its plumbing, installation of water -conserving plumbing fixtures is not technically feasible. (c) A building for which water service is permanently disconnected. 1101.8. A city, county, or city and county, or a retail water supplier may do either of the following: (a) Enact local ordinances or establish policies that promote compliance with this article. (b) Enact local ordinances or establish policies that will result in a greater amount of water savings than those provided for in this article. CUPERTINO Address SMOKE 1 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 • buildingacupertino.org 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. I have read and agree to comply with the terms and conditions of this statement Owner (or Owner Agents) N me: Signature ............ f�.. �'::. Vit....... �......:........................................... Date: Contractor Name: Signature................................................................... Lic.#...................................... Date: ................... Smoke and COfwrm.doc revised 03/18/14