819 N SABINA STPermit Types
BLD I ELE I MEC I PLM.
X I X
Permit Number: BL02022-05484
Issued: 01/30/2023
www.anaheim.net/building
(714)765-4626
Quarter Section: 82
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 766 - 6163
Site Address: 819 N SABINA ST, ANAHEIM, CA 92805
Legal Description: N TR 530 BLK A LOT 22 S
APN: 03514119
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 ATTORNEYS 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
Seaton 3700 of the Labor Code, for the performance of the work for which this permit is Issued.
9 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: STATE COMPENSATION INSURANCE FUND Policy No.: 9310552 Expiration Date: 12128/2022
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
worker's compensation laws of Califomia, and agree that, if I should become subject to the worker's compensation provisions of Section 3700 of the
Labor Code, I shall forthwith comply with those provisions.
1/30/23
Signature of Applicant 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):
Lender's Name:
Lender's Address:
LICENSED CONTRACTOR'S DECLARATION:
I hereby affirm under the penalty of Pedury 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.
Contractor Signature
NUMBER EXPIRATION DATE LICENSE TYPE (S)
1063308 02/29/2024 C10
1/30/23
Date