222 N MULLER ST 52CITY OF ANAHEIM
BUILDING DEPARTMENT 2013 CALIFORNIA CODES
200 S. Anaheim Blvd., Suite 145 CODE CYCLE
01/01/2014
Anaheim, CA 92805
EFRF.G7IVF. DA TF
714 765-5153
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: O W ?on , 14016 Date: G ".1
Project address: -Z.2 Z. lV i( -fail e-.,- S -
Property Owner: A�,O" Grro,.p
The undersigned does hereby certify that I am the property 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. All boxes must be checked below
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.
I 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 units with attac ed garages require carbon monoxide detectors.
Signature: U.,07 Date: (0IIto I-)
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)765-4607 Fax SEPT 2015
www.anaheim.net/building B842
SMOKE/ CO ALARM REQUIRED LOCATIONS
Figure 1
6
Bedroom
Attic
Hall
Living Room ' - mlL- Hall
6@D
Basement
Family Room Bedroom
Dining
Living Room
I Kitchen
MMOM
Bedroo ...
Figure 2 4'
Ceiling
Acceptable 4"
Here Never
Here 712"
Top of Detector
Acceptable Here
4j
6 Iwall
Bedroom Figure 4
Kitchen
Figure 3
REQUIRED SMOKE ALARM LOCATION
i ro REQUIRED CARBON MONOXIDE ALARM LOCATION
Garage
Permit Types
BLD ELE ME4m-
Permit
X Number: BLD2023-01408
Issued: 03/24/2023
www.anaheim.netlbuiiding
(714)765-0626
Quarter Section: 46
CITY OF ANAHEIM
BUILDING DMSION
200 S. ANAHEIM BLVD.
(714)765 -5153
Site Address: 222 N MULLER ST 52, ANAHEIM, CA 92801
Legal Description: P BK 35 PG 10 PAR 1
APN: 07259131 "
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.
1 hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certificate of consent to selfinsure 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 workers Compensation insurance carrier and policy are:
Cartier. AMERICAN ZURICH INSURANCE COMPANY Policy No.: WC112580904 Expiration Date: 12/312023
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 worker's compensation provisions of Section 3700 of the
Labor Code, I shall forOmwith comply with those provisions.
Signature of Applicant Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
1 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):
Lender's Name:
Lender's Address:
LICENSED CONTRACTOR'S DECLARATION:
I hereby affirm under the penalty of Perjury that 1 am licensed under provisions of chapter 9 (commencing with Section 7000) of Dhdsion 3 of the Business and
Professions de, and my license Is In full force and effect.
Contractor Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE (Sl
1059711 10/312023 B. C33, C39