Smoke Carbon Self Certification Form
CITY OF CYPRESS
SMOKE DETECTOR AND CARBON
MONOXIDE SELF CERTIFICATION BY
OWNER
Project Address: _________________________________________________________
Permit Number: __________________________________________________________
Property OWNER: _______________________________________________________
I, the undersigned, hereby certify that I am the owner of the above referenced property. I further
certify that smoke alarms and carbon monoxide alarms are present and functional in all the
following locations:
Smoke Alarms and Carbon Monoxide Alarm: On the ceiling or wall outside of each
separate sleeping area in the immediate vicinity of bedrooms or in each hallway outside
of the rooms.
Smoke Alarms: In each room used for sleeping purposes.
Smoke Alarm and Carbon Monoxide Alarm: In each story, including any habitable
basement. (Note: In dwellings or dwelling units with split levels and without an
intervening door between the adjacent levels, a smoke alarm and a carbon monoxide
detector installed on the upper level shall suffice for the adjacent lower level provided
that the lower level is less than one full story below the upper level.)
OWNER Signature: ______________________________________ Date: ________________
California Residential Code (CRC) Section R314.1, CRC R315.2 states in part that existing
dwellings be “…retrofitted with smoke detectors and carbon monoxide detectors when a building
permit is issued for, worked on or in a building that is valued at $1,000 or more.” CRC Section
R314.3, CRC R315.3 defines required locations as indicted above.
NOTE: This Certification is only used when normal access to the interior of the dwelling by the
City of Cypress Building Inspector is not achieved during the course of project construction. It is
normally used for projects such as re-roofing, re-siding, patio covers, photovoltaic solar panels
and the like. THIS CERTIFICATION SHALL BE SIGNED BY PROPERTY OWNER
ONLY.