504 S BOND STPermit Types
BLD ELE MEC PLM
X I X
Permit Number: BLD2023-02481
Issued: 05/19/2023
www.anaheim.net/building
(714)765-0626
Quarter Section: 103
Site Address: 504 S BOND ST, ANAHEIM, CA 92805
Legal Description: N TR 3397 BLK LOT 1
APN:08251101
WORKER'S COMPENSATION DECLARATION:
CITY OF ANAHEIM
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 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 seffdnsure for worker's compensation, issued by the Director of Industrial Relations as provided for by
JC Section 3700 of the Labor Code, for the performance of the work for which this permit is Issued.
I 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 workers Compensation insurance center and policy are:
Cartier: MIDWEST EMPLOYERS CASUALTY COMPANY Policy No.: BNUWC0159066 Expiration Date: 2/1112024
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
workers compensation laws of California, and agree that, it I should become subject to the workers compensation provisions of Section 3700 of the
Labor Code, l shall forthwith comply with those provisions.
Juan Contreras
Signature of Applicant
Date
5/19/2023
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
1 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 Perjury 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.
ENERGY SERVICE PARTNERS INC DBA ESP CONTRACTING
Contractor Signature
NUMBER
EXPIRATION DATE
LICENSE TYPE (S)
619149 11/30/2023 B, C10
5/1912023
Date