874 S STATE COLLEGE BLVD (2)BUILDING DIVISION
CITY OF ANAHEIM
BUILDING DEPARTMENT 2013 CALIFORNIA CODES
200 S. Anaheim Blvd., Suite 145 CODE CYCLE
Anaheim, CA 92805 01/01/2014
714 765-5153 EFFECTIVEDnrE
www.anaheim.net/building
SMOKE DETECTORS AND CARBON MONOXIDE SELF CERTIFICATION
* Final inspection approval will require this completed form to be on site along with the job card.
Permit Number: _'94-D 29Z " C6 Date: O / a
Project address: % :51
Property Owne : V"Lg7e-1--;-
The undersigned does hereby certify that I am the property owner of the above
property. I further certify that smoke alarms and carbon monoxide alarms are I
functional in all the following locations. All boxes must be checked below
referenced
resent and
❑ Smoke Alarms and Carbon Monoxide Alarm: On the ceiling or wall outside of each separate
sleeping area in the immediate vicinity of bedroom/s 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.)
All dwelling u its with attached garages require carbon monoxide detectors.
Signatur Date:
California Residential Code (CRC) Section R314.6.2,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 work on or
in a building that is valued at $1,000 or more." CRC Section R314.3, CRC R315.2 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 Anaheim
Inspector is not achieved during the course of project construction. It is normally used for exterior projects such
as re -roofing, re -siding, patio covers, solar photovoltaic installations, and similar exterior construction work.
200 S. Anaheim Blvd., Suite 145 Anaheim, California 92805 (714)765-5153 Phone (714)7654607 Fax SEPT 2015
www.anaheim.net/building B842
Permit Types
BLD ELE MEC PLM
X X
Permit Number: BLD2022-05955
Issued: 02/06/2023
www.anaheim.nef/building
(714)765-4626
Quarter Section: 114
CITY OF ANAHEIM
I BUILDING DMSION
200 S. ANAHEIM BLVD.
(714) 765 - 5153
Site Address: 874 S STATE COLLEGE BLVD, ANAHEIM, CA 92806
Legal Description: N TR 2350 BLK LOT 83
APN: 25311210
WORKER'S COMPENSATION DECLARATION:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES
AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED
FOR IN SECTION 3706 OR THE LABOR CODE. INTEREST, AND ATTORNEY'S FEES.
I hereby affirm under penalty of perjury one of the following declarations:
1 have and will maintain a certificate of consent to self -Insure for worker's compensation, issued by the Director of Industrial Relations as provided for by
Section 3700 of the Labor Code, for the performance of the work for which this permit is issued.
I have and will maintain worker's compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which
this permit Is issued. My worker's Compensation insurance carrier and policy are:
Cartier. CAROLINA CASUALTY INSURANCE COMPANY Policy No.: BNUWC0157873 Expiration Date: 9/8/2023
Name of Agent: Phone No.:
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
workers compensation laws of California, and agree that, if I should become subject to the workers compensation provisions of Section 3700 of the
Labor Code, I shall forthwith comply with those provisions.
Signature of plicant Date -
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work for which this permit Is Issued
(Sec.3097.Civ.C):
Lenders Name:
Lenders Address:
LICENSED CONTRACTOR'S DECLARATION:
I hereby affirm under the penalty of Perjury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions Code,and my license Is in full force and effect.
ZZ-
. ;W
Contrac r Signature
NUMBER EXPIRATION DATE LICENSE TYPE (S)
1083866 11/30/2023 C10, A. B
Date