2738 E VIRGINIA AVEBUILDING DEPARTMENT bV iJ �.AYliYN�lff bVLGJ
200 S. Anaheim Blvd., Suite 145 CODE CYCLE
Ol/01/x014
Anaheim, CA 92805 DAT E
EFFECTIVE DATE
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: gtp 10 a vy S� % j Z Date:—/ t—1 3--7,6
^— - — . . eI d ► 1 _
Project address:
Property Owner: 1- lq cari o tlno v
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
VC 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 units wjtMttachec/jarages require carbon monoxide detectors.
Signature:
12
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
Family Room
Bedroom
Dining
Living
Room
Kitchen
Bedroom
Bedroom
Figure 1 Figure 2 _ ' j 4'
Ceii. I
Acceptablf a"
Here 'r
' -T12'
Attic Top
Acct:,. : dere
Wall
Bedroom Hall Bedroom Figure 4
Living Room Hall Kitchen
&@D
Basement rrr,7 Garage
Figure 3
REQUIRED SMOKE ALARM LOCATION
REQUIRED CARBON MONOXIDE ALARM LOCATION
Permit Types
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:
W. I have and will maintain a Certificate of consent to selfainsure for worker's compensation, Issued by the Director of Industrial Relations as provided for by
QC
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. STATE COMPENSATION INSURANCE FUND icy 1846038 Expiration Date: 1/1/2023
Name of Agent: v Pd No.: x
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 awto'become subject to the
worker's nation laws of California, and'agree that, If I should become subject to the worker's compe
Labor nsation pibvisions of Section 3700 of the
de, l hall fo with Comply with those provisions.
Sign ure of Applicant �- ~ -
Date �.. .�. ....._---
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
1 -hereby of ffmunder penal1y-o4erjuW4h the
(Seo.3097.Civ.C): nty4oF4he-performance of -the work for-which-tpis�ermiNs tar••
Lender's Name:
Lender's Address:
LICENSED CONTRACTOR'S DECLARATION:
1 herebyArm under the pe ty f Perjury I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
P►of Code, and m liven is in full acid effect '
Contractor Signature
Date
NUMBER EXPIRATION DATE - LICENSE TYpp
143547 07/31/2023 C39