B-2017-1813 •
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1813
7551 SQUIREWOOD WAY CUPERTINO,CA 95014-5014(362 27 003) HOMEOWNER
BUILDER
OWNER'S NAME:,Satya Sreedhar Mantha And Kameswari Vijayasanthi Sista DATE ISSUED: 10/24/2017
OWNER'S PHONE:408-442-7645 PHONE NO:
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Lic.#
Contractor HOMEOWNER BUILDER Date X BLDG _ELECT X PLUMB
X 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:
INSTALL(N)AC UNIT AND DUCT WORK;RELOCATE FURNACE TO
I hereby affirm under penalty of perjury one of the following two declarations: ATTIC;(N)GAS LINE=STOVE
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. Sq.Ft Floor Area: Valuation:$11000.00
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 362 27 003
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 understands and will comply with all non-point
source regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 10/24/2017 Issued by:Abby Ayende •
Date: 10/24/2017
OWNER-BUILDER DECLARATION
I hereby affirm that I am 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. 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.
ale(Sec.7044,Business&Professions Code)
.„' ,as owner of the property,am exclusively contracting with licensed Signature of Applicant:
4.' contractors to construct the project(Sec.7044,Business&Professions Code), Date: 10/24/2017
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
performance of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
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
Pt'' maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permitis issued. Health&Safety Code,Section 25532(a)should I.store or handle hazardous
a. 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
shall not employ any person in any manner so as to become subject to the air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sectio+s,2551- 25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. foriNNVor authorized agent: I • •
APPLICANT CERTIFICATION Date:10/24/2017
I certify that I have read this application and state that the above information is CONSTRUCTION LE . ► AGENCY
correct.I agree to comply with all city and county ordinances and state laws I hereby 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 Lender's 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 shallbe used as public records.
•
ure ,'11�r • Date 10/24/2017, Licensed
Professional
w
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
,..010300 TORRE'AVENUE • CUPERTINO, CA 95014-3255
s (408) 777-3228 • building@cupertino.org PEMIT#B-��I- - 1$13
CUPERTINO REV# DEF#
❑ NEW CONSTRUCTION ❑,/ADDITION ALTERATION 111T.I. CI MEP ❑RE-ROOF ❑SWIMMING POOL/SPA
PROJECT ADDRESS 755/ 5124 ,�12F hX O..0 /o AY APN R P_� 21'00
CLIP Al2r/a4 - 9 Sa/4 vlT1 V
OWNER NAME S',A7 y,4 s✓I4N7//4 PHONE E-MAIL
//(AmrsLoAils v,SAyA5AnoTH/ SI_514 4'L -`/42-76+5 S yairano4a 7,Qfr,7Poo1 coin
STREET ADDRESS CITY,STATE,ZIP
7657 $ (J / ,/) A70 % E f_, EPT/w,0 , a, 14
❑CONTRACTOR NAME a OWNER-BUILDER COMPANY NAME LICENSE NUMBER LICENSE TYPE
ISTREET ADDRESS CITY,STATE, ZIP I
E-MAIL PHONE BUS.LIC I
❑ARCHITECT ❑OWNER.❑OWNER AGENT 0 CONTRACTOR AGENT 0 ENGINEER 0 DEVELOPER ❑,TENANT
CONTACT NAME E-MAIL
STREET ADDRESS CITY,STATE,ZIP PHONE
DECRIPTO
1,A..5 I I Ct.k o 1-, o N e...t,A) 4 I C % b-t...t_c_ e-.) o I<, Itilo ve
1tAJ. po,T v“,.CQ- ifk d m Cioiist 1' -9-o 1 c Cl 6o1A Cove sy-k-A -e S -o v2_
lc--b ry\ lz_._c_Nyi c_a--)k -1-b . S v-e 3„`.S U tom' s
R NGLE-FAMILY/DUPLEX 0 MULTI-FAMILY ❑INDUSTRIAL ❑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 V ❑DETACHED
EXISING ❑YES EICHLER ❑ YES SECOND STORY ADDITION ❑YES
FIRE SPRINKLERS 0 NO 0 NO 0 NO
DWELLING SECOND DWELLING ❑YES ❑ATTACHED❑DETACHED OTHER
UNITS UNITADDITON: ❑NO SF
POOL'S' ❑FIBERGLASS ❑VINYL-LINED ❑GUNITE 0 PREFABRICATED
POOL-SF SPA-'SF I SPA ATTACHED ❑YES 0 NO I TOTAL-SF
RE VED BY: / v ._,�. eftet
Commercial or Multi-Family Buildings with Public Swimming Pools requires Department of Environmental Heath approval Iv(A"l11 tt1'000 OD
RE-120OFI EXISTING ROOF TYPE: ❑BUILT-UP ROOF❑ASPHALT SHINGLES WOOD SHAKES❑WOOD SHING ES❑TILE OTHER(SPECIFY)
REMOVE/REPLACE❑NO IF NO PLYWOOD CI 1/2" ❑3/8" PLYWOOD TYPE: PITCH: ROOF CLASS
DYES F OF LAYERS THICKNESS❑5/8" OTHER ❑OSB ❑CDX OTHER •12 A
PROPOSED ROOF TYPE:❑BUILT-UP ROOF ❑ASPHALT SHINGLES 0 WOOD SHAKES❑WOOD SHINGLES ❑OTHER
V
*Provide a signed copy of the Cupertino's Tear-Off Policy SF not SQUARES
By my signature-below I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I
have read this application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree
to comply with all applicable local ordinances and state laws relating to building construction. I authorize representatives of Cupertino to
enter the above-identified property for- sp-.' purposes. I acknowledge and authorize all information contained on this application form
to be made available for public r-c.r..
Signature of Applicant/Agent: v:_� A, 4111PDate: 101.2-I fi-DR -
SUPPLEMENTAL INFORMATION REQ
*New SFD/Second Dwelling Units/Multifami�yy swellings:A Demolition permit is required prior to issuance of a building permit for all new construction.
*Commercial 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
\,° f OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
1=� 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
(408)777-3228•FAX(408)777-3333•building(a cupertino.orq
CUPERTINO
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 755/ seevi 2 '4.7DOf fail y/ APN 12:1-0 BP# ?)..1,01.3 y zv3
e t..)Pe 1 r/wra _ 95-D14,
OWNER NAME EA T)/A nlAN'THA OWNER ADDRESS
AlgnoF$`i, A/P/ VUA/A5AN%J1/ 3/51p
DESCRIPTION OF WORK: e#4,J6iN!n /U/2/VACF To 471/C 4 A')/,vlq AA
'/9e✓i/Fli1T/n/f� L/VD/�0:�/7!✓ 37,5 V/= %/J AAA ,STB ii F
• 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.,l'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 unlicensedperson and his or her employees while working on my property. My homeowner's insurance maynot
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
prot ct myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
name instead of my own.
. 2:144.1I understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
5..I 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.
SSTA6.;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.
SSS f\7.1 I 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.
1 . 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.
OwnerBuilderFor,n 2010.doc revised 04/14/10
g:AA 9. I understand I may obtain more information regarding my obligations as an "employer"from the Internal
Revenue Service, the United States Small Business Administration,the California Department of Benefit Payments,
and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State
License Board (CSLB)at 1-800-321-CSLB (2752)or www.cslb.ca.gov for more information about licensed
contractors.
SSV\ 10. I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I
am the party legally and financially responsible for proposed construction activity at the site address listed above.
SS6 11. I 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.
SS° 'I 12. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
information I have provided on this form. Licensed contractors are regulated by laws 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 an unlicensed 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 responsible for verifying whether or not
those Contractors are properly licensed and the status of their workers'compensation insurance coverage,
CONSTRUCTION LENDING AGENCY
(DIRECTIONS:Please complete the following construction lending agency information.)
I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued
(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 acceptable to the city may be required to be presented when the permit is issued
to verify the property owner's signature r
Property Owner's Signature: �. .7 � i—• Date: 4O/I-4,12D)9-
(NOTE:
7 ,12 )9-
(NOTE: The following Authorization Form is required to be completed by the property owner only when designating an
agent of the property owner to apply for a construction permit for the Owner-Builder).
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 my project.
Scope of Construction Project(or Description of Work):
Project Location or Address:
Name of Authorized Agent: Tel No
Address of Authorized Agent:
I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out 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
signature.
Property Owner's Signature: Date:
OwnerBuilderForm_2010.doc revised 04/14/10
t 11 c (1?7-0 9
CERTIFICATE OF VERIFICATION CF3R-MCH-20-H
Duct Leakage Diagnostic Test f 3)
Project Name: tya Enforcement Agency: City of Permit Number:• B-2017-1813
Cupertino
Dwelling Address:. 7551 squirewood way Ci : Cupertino Zip Code: 95014
A.System Information
01 Space Conditioning System Identification or Name System 1
02 Space Conditioning System Location or Area Served Location 1
03 Building Type from CF-1R Single family
04 Verified Low Leakage Ducts in Conditioned Space(VLLDCS) No,credit is not taken
Credit from CF1R?
05 Verified Low Leakage,AirHandling Unit(VLLAHU)Credit No,credit is not taken
from CF1R?
06 Duct System:Compliance Category -=- Alteration using smoke test
; ,::
�. f l
MCH-20e-Sealing All Accessible'Leaks using SmokelTest
B. Duct Leakage Diagnostic Test F { °` r,.
01 Condenser Nominal Cooling Capacity(ton) 3
02 Heating Capacity(kBtu/h) 60
03 Conditioned Floor Area served by this HVAC system(ft2) ' 1600
04 Duct Leakage Test Conditions Test final
05 Duct Leakage Test Method Total leakage
06 Leakage Factor 0.15
07 Air Handling Unit Airflow(AHUAirflow)Determination Cooling system method
Method
08 Measured AHUAirflow This field or section is not applicable
09 Calculated Target Allowable Duct Leakage Rate(cfm) 180
10 Actual Duct Leakage Rate from Leakage Test 182
Measurement(cfm)
Registration Number: Registration Date/Time: 2017-11-20 16:58:13 HERS Provider:CaICERTS
217-A026540240A-000-001-M20001A-M20A
CA Building Energy Efficiency Standards Report Version:2016.1.006 Report Generated:2017-11-20 16:58:23
2016 Residential Compliance Schema Version:rev 03/16
CERTIFICATE OF VERIFICATION CF3R-MCH-20-H
Duct Leakage Diagnostic Test (Page 2 of 3)
B. Duct Leakage Diagnostic Test
System passes using smoke test of an altered HVAC system in an existing building.No
visible smoke exits the accessible portions of the duct system.Smoke is only emanating
from air-handling unit(AHU)cabinet and non accessible portions of the duct system. Note
11 Compliance Statement: -Accessible is defined as having access 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'tnormal operation condition. No temporary taping allowed.
Outside air(OA)duct connections to the central forced air duct system shall not be sealed/taped off during duct leakage
02 testing OA ducts used for Central Fan Integrated(CFI)Indoor Air Quality ventilation systems,or Central Fan Ventilation
Cooling Systems,that utilize darripers'that open_only when OA is required and automatically close when OA is not required,
may configure the OA damper to the closed position during duct leakage testing
03 All supply and return registerboots were sealed to`the drywall -:
04 Building cavities were not used as plenums or platform returns inlieuof ducts .:'
f >i ":a• 4 fqj
05 If cloth backed tape was used it was covered with Mastieand-'draw bands. t ' !' ja
06 All connection points between the air handler and the supply and return plenums are completely sealed.
If the system complies using the Smoke Test method,the smoke test was conducted in accordance with the requirements
07 of Reference Residential Appendix RA3.1.4.3.6.Systems that comply using smoke test shall not be included in sample
groupsfor HERS verification compliance.
.I
08 Verification Status:: Pass-all applicable requirements are met
09 Correction Notes:
' The responsible person's 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.
D. Determination of HERS Verification_Compliance
All applicable sections of this document shall indicate compliance with the specified verification protocol requirements in order
for this Certificate of Verification as a whole to be determined to be in compliance.
01 Complies:All specified verification protocol requirements on this document are met.
Registration Number: Registration Date/Time: 2017-11-20 16:58:13 HERS Provider:CaICERTS
217'A026540240A-000-001-M20001A-M20A
CA:Building Energy Efficiency Standards Report Version:2016.1.006 Report Generated:2017-11,20 16:58:23
2016 Residential Compliance Schema Version:rev 03/16
CERTIFICATE OF VERIFICATION CF3R-MCH-20-H
Duct Leakage Diagnostic Test (Page 3 of 3)
Documentation Author's Declaration Statement
1. I certify that this Certificate of Verification documentation is accurate and complete.
Documentation Author Name: Documentation Author Signature:
Raman Najjarian % Ge4V1*iLII:21fi
Company: Date.Signed:
Raman Najjarian 2017-11-20 16:58:13
Address: CEA/HERS Certification Identification'(if applicable):
1520 Branham Ln Apt#46 Cc2016084
City/State/Zip: Phone:
San Jose CA 95118 408-724-0663
Responsible Person's Declaration statement
I certify the following under penalty:of perjury,under the laws of the State of California:
1. The information providedion'this Certificate of Verification is true and correct.
2. I am the certified HERS Rate?pho performed the verification identified and reported on this Certificate of Verification(responsible rater).
3. The installed features;_materials,components,manufactured devices,or system performance diagnostic results that require HERS verification
identified on tbis.Certificate'of verification comply with.the.applicable requirements in Reference Appendices RA2,RA3,and the requirements
specified`on"the Certificatelof Compliance for`_the'building approved by the enforcement agency.
4.• The information reported0 applicable"sections of-the CertificaYe(s),of Installation(CF2R)signed•and submitted,;by the person(s)responsible for the
construction or insstallationlconforms to the.requirements specified'on the Certificate(s)of Compliance(CF1R)approved by the enforcement agency.
5. I will ensure that a registered copy of this Certificate of,Ver.ification'shall be posted or made available with the;building permit(s),issued for the
building,and made available to the;enforcement agencyfor all applicable inspections I understand that airegistered{copy ofithis:Certificate.of ;�-
Verification islrequired to be'iincluded with the documentation the builderprovides to the building owner at`occupancy.
' ^ -4.. It ^. ,q 7„-T .:"•'. Y'q .�.,..:L '.. ..s art: S_ �45 *•x.. a+w,u. _
i I ,,. r.... cafe Of Installations 'L.41 �a t
Builder Or;Installer Information As Shown On The'JCertifi Il �. 4
Company Name(Installing Subcontractoreneral Contractor,or Builder/Owner):
Homeowner-Installer
Responsible:Builder or Installer Name: CSLB License:
Satya,S Mantha HOMEOWNER
HERS,Provider Data Registry Information
Sample Group Number(if applicable)': Dwelling Test Status in Sample Group(if applicable)
Tested
HERS Rater Information
HERS Rater Company Name:
Raman Najjarian
Responsible Rater Name: Responsible Rater Signature:
Raman Najjarian % tAft�R#.A4L2/fi
Responsible Rater Certification Number w/this HERS Provider: Date Signed:
CC2016084 2017-11-20 16:58:13
Digitally signed by Ca10ERTS. This digital signature is provided in order to secure the contentof this registered document,and in no way implies
Registration Provider responsibility for the accuracy of the information.
Registration Number: Registration Date/Time: 2017-11-20 16:58:13 HERS Provider:CaICERTS
217-A026540240A-000-001420001A-M 2OA
CA Building Energy Efficiency Standards Report Version:2016.1.006 Report Generated:2017-11-20 16:58:23
2016 Residential Compliance Schema Version:rev 03/16
SMOKE / CARBON MONOXIDE ALARMS
rik,› OWNER CERTIFICATE OF COMPLIANCE 11—?-7-17
o
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION •
CUPERTINO 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
(408)777-3228•FAX(408)777-3333•buildinc a)cupertino.orq
- r'i � Yx. z awn w -: +� k ""fir -�. a' z^S
,7 A
PE' 6 ,CANNOT BE FINALED!UNTIL THIS CERTIFICATE 1iAS BEE i i
�s �:. 7 c�' a,.,� �7 ��+ z- P' tee^' �%r1 i.v �,a«'� x s§ '€f��"�q .� � x r �s .f
�` COMPLETED SIGNED.AICD RETURNED TO THE B s o NG�DI'�ISIOI 4,
in .� z�vME`V
• rs.-,* .._«...„,.e:�z�au�� -. ^.. ...w.,� „,..-<, •”•_...;axe- ::ucc. .x ---?as>x" -..:_,; .»:,.._.,.. =a.,�.s,.,..T.«R.w*,.`��,`
PURPOSE
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 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. nn
Address: 55\ So 7Cl�reC.Obo N Ccife:Ai61n C f} 95-01 CTermit No. 17 1 /U u
l 3
Specify Number of Alarms: #Smoke Alarms: I .1 I #Carbon Monoxide Detectors: I I
I have read and agree to comply with the terms and conditions of this statement
Owner(or Owner Agent's)Name:
/ �"IIATIU7 Signature....` .�,�.czNo
Date:I 1.I. zO(
Contractor Name:
Signature Lic.# Date:
Smoke and CO form.doe revised 01/10/2017