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AFFIDAVIT SELF-CERTIFICATION
FOR COMPLIANCE OF SMOKE ALARMS
AND CARBON MONOXIDE ALARMS
Property Address: 939 ,44l-:I l 1J//. / iJE'
Permit Number: BOO. O'-1 6 J(f 0
Brief Job Description: 14 VA C... �?b T s ( /kxJG€. 60 T.
Number of smoke alarms installed: G Li
Number of carbon monoxide alarms installed: 43)11...49/NC, /S Ate_ tc.cz or iC
When alterations, repairs or additions requiring a permit occur, or sleeping rooms are created,
Smoke alarms shall be installed in each sleeping room, and outside each separate
sleeping area in the immediate vicinity of the bedrooms, and on each additional story of the
dwelling, including basements and habitable attics as required by Section R314 of the 2013
California Residential Code (CRC) and California Health and Safety Code Section 13113.7.
For dwellings or sleeping units containing fuel burning appliances or having attached
garages, carbon monoxide alarms shall be installed outside each separate sleeping
area in the immediate vicinity of the bedrooms, and on each additional story of the
dwelling, including basements as required by Section R315 of the of the 2010 California
Residential Code (CRC).
Multi-purpose alarms (combination carbon monoxide and smoke alarms) may be used.
All alarms shall comply with requirements for listing and approval by the Office of the State Fire
Marshall. http://osfm.fire.ca.qov/licensinglistings/licenselistinq bml searchcotest.php
As owner of the above referenced property, I hereby certify that the smoke alarms and carbon
monoxide alarms have been installed in accordance with the manufacturer's instructions and in
compliance with the code sections referenced above.
I declare under penalty of perjury that the fore oing is true and correct, and that this
declaration was executed on (Date) /2- - / V at Arcadia, California.
Owner's Name (printed/typed): A-Nra I12 A , AtQ i3t)1�
Signature of Owner: l 1iV Caw��'�--
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This affidavit must be returned to the City of Arcadia inspector prior to final inspection
SMOKE ALARM AND CARBON MONOXIDE ALARM LOCATIONS
Guest Room y
c Bathroom
Storage
Family Room
Garage
FIRST FLOOR PLAN
0= SMOKE ALARM = CARBON MONOXIDE ALARM
Mstr
L_ Bath
Master Bedroom
Dining Room Kitchen
Bat)
4
Hall Q
Closet
1 Closet Closet
Family Room
Bedroom Bedroom
SECOND FLOOR PLAN
0=SMOKE ALARM = CARBON MONOXIDE ALARM