372 S SMOKERIDGE TER (5)Permit Types
BLD I ELE I MEC PLM
X I X
Permit Number: OLD2023-01323
Issued: 04/1212023
www.anahelm.net/buliding
(714)7654626
Quarter Section: 180
CITY OF ANAHEIM
Site Address: 372 S SMOKERIDGE TER, ANAHEIM, CA 92807
Legal Description: N TR 8783 BLK LOT 22
APN: 36324218
BUILDING DIVISION
200 S. ANAHEIM BLVD.
17141765.5153
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:
I 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.
1 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:
Carrier: Policy No.: Expiration Date:
Name of Agent: Phone No.:
a
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 comps setion laws of California, and agree that, if I should become subject to the workers compensation provisions of Section 3700 of the
Lab r Code, shall forthwith comply With those provisions.
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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:
Lender's Address:
LICENSED CONTRACTOR'S DECLARATION:
I hereby affirm under the penalty f Perjury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professlonsde ndWy ii se Is in full force and effect.
Contractor Signtur Date
NUMBER EXPIRATION DATE LICENSE TYPE (SI
925791 12/31/2024