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B-2017-0785 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-0785 19351 CALLE DE BARCELONA CUPERTINO,CA 95014-3403(375 04 008) MIDLANDS RESTORATION INC CAMPBELL,CA 95008 OWNER'S NAME: CHUA THAI CHENG DATE ISSUED:07/05/2017 OWNER'S PHONE:408-332-8028 PHONE NO:(408)379-9852 LICENSED CONTRACTOR'S.DECLARATION BUILDING PERMIT INFO: License Class B Lic.#736056 Contractor MIDLANDS RESTORATION INC Date 05/31/2019 X BLDG _ELECT _'PLUMB MECH X RESIDENTIAL COMMERCIAL • 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. JOB DESCRIPTION: DUE TO TREE DAMAGE-REPLACE(E)DAMAGED ROOF 1 hereby affirm under penalty of perjury one of the following two declarations: FRAMING OVER FAMILY ROOM;REMOVE ARBOR(126 SQ FT); i. I have and will maintain a certificate of consent to self-insure for Worker's REPLACE DUCT WORK. Compensation,as provided for by Section 3700 of the Labor Code,for the REV#I RE-ROOF;INSTALL TAR ROOF-(13 SQ)-ISSUED 10/10/2017 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. Sq.Ft Floor Area:• Valuation:$750.00 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 APN Number: Occupancy Type: and state laws relating to building construction,and hereby authorize 375 04 008 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 PERMIT EXPIRES IF WORK IS NOT STARTED may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR Additionally,the applicant`und ands and will comply with all non-point source regula' the`Cu rtino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. Si a' e !/ Date 10/10/2017 Issued by:Kim Dunbar Date:07/05/2017 OWNER-BUILDER DECLARATION ) I hereby affirm that I ant exempt from the Contractor's License Law for one of the RE-ROOFS: following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is 1. 1,as owner of the property,or my employees with wages as their sole installed without first obtaini : .n inspectio. 1 agree to remove all new materials for compensation,will do the work,and the structure is not intended or offered for i ins. cti.' . sale(Sec.7044,Business&Professions Code) 3f;"' v�i-,',.�yt. z. I,as owner of the property,am exclusively contracting with licensed i1„I , e of Applicant: contractors to construct the project(Sec.7044,Business&Professions Code). I'D,;,,e: 10/10/2017 I hereby affirmunder 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 , performance of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE 2. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the Section 3700 of the Labor Code,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534. I will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the 3. I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(a)should I s re or handle hazardous shall not employ any person in any manner so as to become subject to the material. Additionally,should I u -: ipment or •evices which emit hazardous air contaminants as defined by e Bay • rex Air uality Management District I Worker's Compensation laws of California. If,after making this certificate of will maintai,n��,A,,, pliance wit, the Cup, tin u icipal Code,Chapter 9.12 and exemption,I become subject to the Worker's Compensation provisions of the ,lf°e�Illth&Safet Cod:—sectio 550`, 533,and 25534. Labor Code,I must forthwith comply witlrsuch provisions or this permit shall i 4 = be deemed revoked. 0..''r' authorized agent: APPLICANT CERTIFICATION , = ''i . i I certify that I have read this application and state that the above information is I. CONSTRUCTION LENDING AGENCY correct.I agree to comply with all city and county ordinances and state laws ereby affirm that there is a construction lending agency for the performance relating to building construction,and hereby authorize representatives of this city of work's for which this permit is issued(Sec.3097,Civ C.) to enter upon the above mentioned property for inspection purposes. (We)agree Lenders Name to save indemnify and keep harmless the City of Cupertino-against liabilities, judgments,costs,and expenses which may accrue against said City in . Lender's Address consequence of the granting of this permit. Additionally,the applicant understands • and will comply with all non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION , Code,Section 9.18. I understand my plans shall be used as public records. Licensed r , Signature Date 10/10/2017 Professional CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION V 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 4,... :�° (408) 777-3228 • building@icupertino.org PEMIT#B- 201 7"6.725 CUPERTINO REV# t DEF# ❑ NEW CONSTRUCTION ❑ADDITION ❑ALTERATION ❑T.I. ❑MEP 1=1 RE-ROOF ❑SWIMMING POOL/SPA PROJECT ADDRESS 1 93 5 aiic , kc-16,4 APNit 31 5— O q o Cf47 OWNER NAME / /i • ..11 v� PHONE 3 3 �im^rE-MAIL STREET ADDRESS /�'Yl^' CITY STATE,ZIP I S- e u z �,�,�p1 cA- gid i 51 ELCONTRACTOR NAME ❑OWNER-BUILDER COMPANY Iro s ���B�ENSE NUMBER LICENSE TYPE fi in D rM icee{rS c//!///pi on) !‘e)Cg 3 1 STREET.57e0-ADDRESS V i v j./d) C STATE, Z� I ^��a I E-MAIL �` / ,j PHONE (�/�C 7f- r Q ^ G/f u Q lib 5A 4e;@ 'h1-ClJtuf.Pfri(P ["0 7 q 0 �/ BUS.LICtl �� ! / 0 ARCHITECT 0 OWNER ❑OWNER AGENT 0 CONTRACTOR AGENT ENGINEER 0 DEVELOPER❑TENANT CONTACT NAME , E-MAIL STREET ADDRESS CITY,STATE,ZIP PHONE DECRIPTON i(r-pii10. Sma A ekid Aeolvi -Fitc-c DAYnier--,.- 'errigleife sbecr-i• _ Wij 'Derive !v civ-Fre26 ! '' 4 v goo/ ,(SINGLE-FAMILY/DUPLEX 0 MULTI-FAMILY 0 INDUSTRIAL 0 COMMERCIAL I EXISTING USE EXISTING SF NEW FLOOR SF PORCH SF DECK SF DEMO SF STORIES I TOTAL NET SF USE TYPE OCC SQ.FT. VALUATION($) REMODEL REMODEL KITCHEN REMODELOTHR GARAGE ❑ATTACHED BATHROOM SF SF SF SF 0 DETACHED EXISING 0 YES EICHLER 0 YES SECOND STORY ADDITION 0D YES FIRE SPRINKLERS 0 NO 0 NONO DWELLING SECOND DWELLING DYES ❑ATTACHED❑DETACHED OTHER UNITSI UNITADDITON: 0 N SF r POOLS ❑ FIBERGLASS 0 VINYL-LINED 0 GUNITE 0 PREFABRICATED POOL-SF SPA-SF I SPA ATTACHED❑YES 0 NO I TOTAL-SF 4---� RECEIVED µ.4 J/. //11-14A O Commercial orMulti-Family Buildings with Public Swimming Pools requires Department of Environmental Heath approval J OQ vt RE-ROOF EXISTING ROOF TYPE: ❑BUILT-UP ROOF❑ASPHALT SHINGLES WOOD SHAKES I,]WOOD SHINGLES❑TILE OTHER(SP IFY)(i eA B4O4R1 , REMOVE/REPLACE❑NO IF NO PLYWOOD ❑1"" ❑3/8" PLYWOOD TYPE: __w P'IITAACH: /� ROOF CLASS EYES I OF LAYERS THICKNESS El 5/8" OTHER ❑OSB El CDX OTH ERt 1n eo2,0 Nth __Z:2_•12 A PROPOSED ROOF TYPE:❑BUILT-UP ROOF DASPHALT SHINGLES 0 WOOD SHAKES❑WOOD SHINGLES 0 OTHER rtarg&itaXib '\ *Provide a signed copy of the Cupertino's Tear-Off Policy SF I . L`�'Aof SQUARES (3 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 s correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordina an. s :to law relating to building construction. I authorize representatives of Cupertino to enter the above-identified property fo 'Tspecti.• .urposes. cknowledge and authorize all information contained on this application form to be made available for public rec.. .. 1 Signature of Applicant/Agent: Date: A—/o—/7 SUPPLEMENTAL INFORMATION REQUIRED "New SFD/Second Dwelling Units/Multifamily Dwellings:A Demolition permit is required prior to issuance of a building permit for all new construction. "Coinmercial Buildings: Provide a completed Hazardous Materials Disclosure form if any Hazardous Materials are being used as part of this project. *Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application. "HOA-Provide a letter of approval from the Home Owner's Association BldgApp_2017.doc revised 08/01/17 REROOF TEAR-OFF POLICY yzo _ COMMUNITY DEVELOPMENT DEPARTMEINJ•BUILDING DIVISION ALBERT SALVADOR, P.E., C.B.b.,BUILDINGoF6OIAL lefr?.25! 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 (408)777-3228*FAX.(408)777-3333•buildiagaetiortineorg ADORE:SS IA_ C. -//e 4 C-Y (114 • I b 0 '4 0 07 OWNER NAME ,c..1 PHONE* 5 9.)„,8_0 LiA STREET ADDRESS5CITY, STATE,ZIP C -thrrIA U. a 5750 'AX CON IRACTO-N ro r*iitidio LICENS5E NI2iTs.4 1 LICENSE rypiE 3 Li co 14i COMPA,NY NAME . FAX 51.40/ '1-C:siva-.Corl •STREET A1114PS C STATE. #Cere " ' 1 7182 5 6 Di V)cidn) I UNDERSTAND AND AGREE TO TUE FOLLOWING: 1. The re-roof project shall comply with all applicable provisions of the 2016 California Codes. 2. An inspection request.call be scheduled up to one business..da*.before the requested inspection.date. , To schedule inspections:call (408) 777-3228 from 1:304.3:40(IgOrt-Thurs) or 7:30-2:30pm(Friday) to schedule inspection. For Tear-Off and Nailing InspectionS„you must also call on the day of the inspection only after that phase of the work is completed;The blinding inspector will be out to the job site within one hour. The hours for this service are: 7:30-10:30arn and. 12:30-3:30 (Mon-Thurs) and 7:30-10:30am and 1.2:30-2:30 (Friday). Final InspectiOnsWillbe given a two hour window. 3. Tear-Off Inspection is required. Any and all dry-rotted wood-shall be replaCed prior to this inspection. Unless new plywood roof sheathing is proposed throughout, all the nails/fasteners shall be either completely knocked-down or removed prior to this inspection. • 4. If plywood is installed, a plYwoodin .gJLLis)eqi2iiiiitai1 tired, 5. Roofing shall not be applied without first obtaining anpriorinspection and written approvals from the building inspector. Any roofing which is applied without firstobtaining an approved inspection will require the removal of all new material down to the sheathing.so a proper inspection can be performed. 6 A Final Inspection andapproval shall be obtained:froth-the':buildina inspector when the re-roofing is completed. To receive a final Sig-Oft the followinglitent: be verified: a. Flat roofs shall hate a minimum of 1/4' per foot of Slope and demonstrate the is no ponding. b. Listings from approved testing agencies for all pre7manufactured products used shall be available on-site to review at.the time of the in.speetion... c. Proper spark.arrestor installation, vents painted., gutter/downspouts installed, debris removed. 7. NOTE: If you call for a tear-off or plywood nailing inspeetion-and the Work is not complete, you will be charged a re-inspection fee. The re-inspection fee sjtaiaLmjAktfore another inspection can be scheduled. 13), my signing below,I certify each of the following is true: I am the property owner or authorized agent to act on the property owner's behalf. I understand and agree NCO]tply with the re-roof policy stated above. I also understand that smoke detectors and carbon mo lde de s•etor5 am re uired to be installed in accordance with Sectio s.R314 and R315 of the 2016 California Residenti,. Code. • .`lanattire of:Applicantl4W: Date: d, / _ Rerog/7oliey_.2014doc revised 06/01,7 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2017-0785 19351 CALLE DE BARCELONA CUPERTINO, CA 95014-3403 (375 04 008) MIDLANDS RESTORATION INC CAMPBELL, CA 95008 OWNER'S NAME: CHUA THAI CHENG OWNER'S PHONE: 408-332-8028 License Class 5 Lic. #736056 Contractor MIDLANDS RESTORATION INC Date 05/31/2019 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: t. 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. 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 re�gulaattions per the Cupertino Municipal Code, Section 9.18. Signa4M �-- �A 1 X� Date 715/2017 OWNER -BUILDER DECLARATION 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) 2. I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). DATE ISSUED: 07/05/2017 PHONE NO: (408) 379-9852 BUILDING PERMIT INFO: X BLDG —ELECT —PLUMB _ MECH X RESIDENTIAL _ COMMERCIAL JOB DESCRIPTION: DUE TO TREE DAMAGE - REPLACE (E) DAMAGED ROOF FRAMING OVER FAMILY ROOM; REMOVE ARBOR(126 SQ FT); REPLACE DUCT WORK. Sq. Ft Floor Area: I Valuation: $0.00 APN Number: Occupancy Type: 375 04 008 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by: Kim Dunbar Date: 07/05/2017 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 of Al Date: 7/5/2017 I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS "A" OR BE r. 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. 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 9.18. Signature Date 7/5/2017 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, Sections 25505 25533, and 25534. Owner or authorized ao:;;�� Date: 7/5/2017 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 ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional CUPERTINO CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building(ftupertino.org B-ZOR- 03?3S ❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION / TI ❑ REVTSION /DEFERRED ORIGINAL PERMIT # PROJECT ADDRESS 19351 CALLE DE BARCELONA AP' a'. 375-04-008 On&t"tHUA PHONT 408-332-8028 E -MAI. STREET ADDREss 19351 Calle De Barcelona CITY, STATE, ZIP FAX Cupertino, CA 95014 CONTACT NAME Jeff Bailey/Shari Parker PHONE 408-379-9852 &MAIL STREET ADDRESS 562 Division Street CITY, STATE,Cam Camp ell, Ca 95008 FAx 408-379-9857 ❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME JM Construction LICENSE NUMBER 7 3 6 0 5 6 LICENSE TYPE BUS. LIC # j I W`(A B 1 N. COPANYNA IE JM Construction E-MAIL FAx 408-379-9857 sTREETADDREsS 562 Division Street crrY,S`ATF-` Campbell, Ca 95008 PHoNE408-379-9852 ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK Reconstruction repairs to residence from tree falling onto property &(Lc,V�M%u� M 0f-� V p4c.c,Q 0.11`.[4- u3cwt-- EXISTIAG USE P PO ED USE CONS IR, TYPE # STO S USE TYPE OCC. SQ.FT. VALUATION (S) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECKIPORCH AREA GARAGE AREA: DETACH I ATTACH # DWELLING UNITS: IS A SECOND UNIT ❑ YBS SECOND STORY ❑ YES BEING ADDED? ❑ NO ADDITION? ❑ NO PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YES REC IVE BY: TOT�I� VAJ.,UATION: PLANNING ADPL # ❑ NO PLANNING APPROVAL LETTER EICHLER HOME? ❑ NO r•'F/� '\�j Jf�I. Cm 1 By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on tAe property owner's behalf. I have read this application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building construction. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes. Signature of Applicant/Agent: Date: SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECK TYPE ROUTING SLIP ❑ OVER-THE-COUNTER New SFD or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building for building. BUILDING PLAN REVIEW permit new ❑ EXPRESS QIIIIPLANNING PLAN REVIEW _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure El STANDARD ❑ PUBLIC WORKS form if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FIRE DEPT _ Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR ❑ SANITARY SEWER DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH B1dgApp_2011.doc revised 06/21/11 qI�pl ►, . \ 1 e,\,,,../ SMOKE / CARBON MONOXIDE ALARMS i E OWNER CERTIFICATE OF COMPLIANCE 4i1-.19,,,, COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION CUPERTINO10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 (408)777-3228•FAX(408)777-3333•building a(�cupertino.orq PERMIT CANNOT BE FINALED UNTIL THIS CERTIFICATE HAS BEEN i COMPLETED,SIGNED,AND RETURNED 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 X X the bedroom(s) • 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 specified below have been tested and are operational, as of the date signed below. � Address: I / 5/ a!/l e �C P'z-cE�(/d/iJf4 Permit No. yW '?-o i 7-67 f5 Specify Number of Alarms: #Smoke Alarms: 13 I #Carbon Monoxide Detectors: I /have read and agree to comply with the terms and conditions of this statement Owner(or Owner Agent's)Name: Signature Date: o ra for Name: 0 ` Sri CIA:rS O.Ar ems 1 Signature - Lic.# ..3.3.e �t7 Date:1/70 Contr N Smoke and CO form.doc revised 09/27/16