648 S BROADVIEW STPermit Types
BLD ELE MEC PLM
X
Permit Number: BLD2023-00411
Issued: 01/26/2023
www.anaheim.net/building
(714)765-0626
Quarter Section: 48
CITY OF ANAHEIM
Site Address: 648 S BROADVIEW ST, ANAHEIM, CA 92804
Legal Description: N TR 2425 BLK LOT 116
APN: 12822408
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 ATTORNEYS FEES.
1 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.
4 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 workers Compensation insurance carder and policy are:
Cartier: STATE COMPENSATION INSURANCE FUND Policy No.: 9303073 Expiration Date: 8/3/2023
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
worker's compensation laws of California, an agree that, if I should become subject to the worker's compensation provisions of Section 3700 of the
LaborComLshwva ply with se provisions. /
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:
Lenders Address:
LICENSED CONTRACTOR'S DECLARATION:
I hereby affirm under the penalty of Perjury that I aicensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license InIALlarraAd effect.
;2
Contractor
Contractor Signatu Date
NUMBER EXPIRATION DATE LICENSE TYPE IS)
977779 10/31/2024 C10