BLD-2023-1303_SignedPermit.pdfSMOKE / CARBON MONOXIDE ALARMS
SELF-CERTIFICATION OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • building@cupertino.org
PERMIT WILL NOT BE FINALED UNTIL THIS CERTIFICATE IS :
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 2022 California Residential Codes (CRC) Section R314 & R315, where no interior access for inspections is required.
You may also grant the inspector access into the residence for on-site verification in lieu of completion of this affidavit.
Note: On site verification of smoke & Co alarms is required when inspection area is within the residence.
GENERAL INFORMATION:
Existing single-family and multi-family dwellings shall be provided with Smoke Alarms and Carbon Monoxide alarms.
Alarms must be models approved and listed by the State Fire Marshal, found at: https://osfm.fire.ca.gov/divisions/fire-
engineering-and-investigations/building-materials -listing/bml-search-building-materials-listing/ . Smoke alarms shall be
listed in accordance with UL 217. Combination smoke and carbon monoxide alarms shall be permitted to be used in lieu
of smoke alarms. Provided they are listed in accordance with UL 217 and UL 2034. When the valuation of additions,
alterations, or repairs to existing dwelling units exceeds $1,000.00, the CRC Section R314 & R315 require s that Smoke
Alarms and/or Carbon Monoxide Alarms be installed and functioning in the following locations:
AREA SMOKE
ALARM
Co ALARM
Within each sleeping room- NOTE: Smoke alarms shall be installed not less than 3 feet :
horizontally from the door or opening of a bathroom that contains a bathtub or shower, from the tip of the
blade of a ceiling-suspended (paddle) fan, and horizontal path from the supply registers of a forced air
heating or cooling system and shall be installed outside of the direct airflow from those registers.
*For additional requirements or clarification see NFPA 72.
X
On every level of a dwelling unit including basements and habitable attics X X
Outside each separate sleeping area in the immediate vicinity of the
bedroom(s). X X
NOTE: Carbon Monoxide alarms are not required in dwellings which do not contain fuel-burning appliances and that
do not have an attached garage.
Power Supply: In existing dwelling units with no commercial electrical supplied to alarms, the smoke and Co 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 & R315. An electrical permit is required for alarms which must be
connected to the building electrical system.
“As Owner or Owner’s appointed agent of the listed property, I hereby certify that the alarm(s) referenced above are
installed in accordance with the manufacturer’s instructions and in compliance with the California Residential Codes.”
Smoke and CO form.doc revised 02/02/2023
Permit #Number: Cupertino Property address:
Property Owner
Name ...................................................................... Signature ................................................................................................................... Date: .................................
Licensed Contractor
Name ..................................................................... Signature ................................................................................................................... Date: ..................................
ITY OF
BUILDING PERMIT
CITY HALL
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
PHONE 408-777-3228
CUPERTINO WWW.CUPERTINO.ORG
BUILDING ADDRESS: 6397 MYRTLEWOOD DR APN: 369 17 006
PERMIT NO: BLD-2023-1303
OWNER'S NAME: GUNDANNA SUDHEER M AND JAYAPRAKASH ROOPASHR
OWNER'S PHONE:408-338-7508
CONTRACTOR: GLENNGARRY CONSTRUCTION INC
CONTRACTOR PHONE:
DATE ISSUED: Au 30. 2023 ISSUED BY:Jasmine Archbold VALUATION: 11500
JOB DESCRIPTION: INSTALL UNCONDITIONED PATIO ENCLOSURE (240 SF); (1) FAN/LIGHT; (2)
LIGHT FIXTURES; (5) OUTLETS; (1) SWITCH
LICENSED CONTRACTOR'S DECLARATION:
NO: 915451 EXP DATE: 05/31/2024
7000) of Division 3 of the Business & Professions
CONTRACTOR: GLENNGARRY CONSTRUCTION INC LICENSED CLASS: B
BUILDINGGENERAL LICENSED
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section
Code and that my license is in full force and effect.
as provided for by Section 3700 of the
I hereby affirm under penalty of perjury one of the following three declarations:
❑ I have and will maintain a certificate of consent to self -insure for Worker's Compensation,
Labor Code, for the performance of the work for which this permit is issued.
Section 3700 of the Labor Code, for the
not employ any person in any manner so as to
this certificate of exemption, I become subject to
with such provisions or this permit shall be
I. I have and will maintain Worker's Compensation Insurance, as provided for by
performance of the work for which this permit is issued.
❑ I certify that in the performance of the work for which this permit is issued, I shall
become subject to the Worker's Compensation laws of California. If, after making
the Worker's Compensation provisions of the Labor Code, I must forthwith comply
deemed revoked.
HAZARDOUS MATERIALS DISCLOSURE
& Safety Code, Sections 25505, 25533, and 25534. I
M I have read the hazardous materials requirements under Chapter 6.95 of the California Health
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or
air contaminants as defined by the Bay Area
Chapter 9.12 and the Health & Safety Code,
handle hazardous material. Additionally, should I use equipment or devices which emit hazardous
Air Quality Management District I will maintain compliance with the Cupertino Municipal Code,
Sections 25505, 25533, and 25534.
EPA LEAD -SAFE DISCLOSURE
No:
❑ An EPA Lead -Safe Certified Renovator will be responsible for this project.
Certified Firm Name: Firm Certification
✓ No EPA Lead -Safe Certified Firm is required for this project.
CONSTRUCTION LENDING AGENCY
of the work which this permit is issued
I hereby affirm under penalty of perjury that there is a construction lending agency for the performance
(Section AV7, Civil Code).
Yes El No
Lender's Name:
Lender's Address:
APPLICATION CERTIFICATION
with all city and county ordinances and state
the above mentioned property for inspection
judgements, costs, and expenses which may
understands and will comply with all non -point
I certify that I have read this application and state that the above information is correct. I agree to comply
laws relating to building construction, and hereby authorize representatives of this city to enter upon
purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities,
accrue against said City in consequence of the granting of this permit. Additionally, the applicant
source regulations per the Cupertino Municipal Code, Section 9.18.
Signature kvaicren Eakei Date Aug 30, 2023
EVERY PERMIT ISSUED SHALL BECOME INVALID UNLESS THE WORK ON THE SITE AUTHORIZED BY SUCH PERMIT IS COMMENCED WITHIN 365 DAYS AFTER ITS ISSUANCE,
OR IF THE WORK AUTHORIZED ON THE SITE BY SUCH PERMIT IS SUSPENDED OR ABANDONED FOR A PERIOD OF 365 DAYS AFTER THE TIME THE WORK IS COMMENCED.