1901 N CITRUS EDGE CIR (2)Permit Types
BLD ELE MEC PLM
X X
Permit Number. OLD202341558
Issued: 04/28/2023
www.anaheim.net/building
(714)765-4626
Quarter Section: 170
CITY OF ANAHEIM
Site Address: 1901 N CITRUS EDGE CIR, ANAHEIM, CA 92807
Legal Description: N TR 7676 BLK LOT 1
APN:34323101
WORKER'S COMPENSATION DECLARATION:
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 - 5153
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 ATTORNEYS FEES.
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certificate of consent to selfuinsure for worker's compensation, issued by the Director of Industrial Relations as provided for by
Mie
Section 3700 of the labor Code, for the performance of the work for which this permit is issued.
,
1 have and will maintain workees 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. STATE COMPENSATION INSURANCE FUND Policy No.: 9286543 Expiration Date: 1022/2023
Name of Agent Phone No.:
I certify that in the performance of the work for which this permit is issued, l shall not employ any person in any manner so as to become subject to the
worker's compensation laws of California, and agree that, if I should become subject to the worker's compensation provisions of Section 3700 of the
LatiolpiCode, I shall forthwith comply with those provisions.
Zr L3
,Sig f - pli
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):
Lender's Name:
Lenders Address:
LICENSED CONTRACTOR'S DECLARATION:
1 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, an y license is In full force and effect.
Date
NUMBER EXPIRATION DATE LICENSE TYPE ISl
1067781 08/31/2024 C10