505 S AMBOY STPermit Types .
BLD ELE I MEC_PLM
X
Permit Number. BLD2023-01904
Issued: 04/21/2023
www.analteim.net/buiiding
(714)765-4626
Quarter Section: 54
Site Address: 505 S AMBOY ST, ANAHEIM, CA 92802
Legal Description: N TR 6451 BLK LOT 8
APN: 25006118
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 - 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 pedury 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 tabor Code, for the performance of the work for which this permit is issued.
1 have and will maintain workers 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.: 9260330 Expiration Date: 917/2023
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
rs compensation laws of Caffomia, and agree that, if I should become subject to the worker's compensation provisions of Section 3700 of the
r Code. I shall forthwith co ly with those provisions.
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�g atreof 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
of Perjury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
e is M full force and
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Date
NUMBER EXPIRATION DATE LICENSE TYPE (S)
1032152 10/31/2023