1406 W BALL RDPermit Types
BLD ELE MEC PLM
X X
Permit Number: BLD2023-00975
Issued: 03/23/2023
www.anaheim.net/building
(714)765-4626
Quarter Section: 65
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 - 5153
Site Address: 1406 W BALL RD, ANAHEIM, CA 92802
Legal Description: S TWP 4 RGE 10 SEC 21 SEC 21 T 4 R 10 POR W1/2 NW1
APN:12926108
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:
1 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.
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 carrier and policy are:
Carrier.
Policy No.: WC614287601 Expiration Date: 10/1/2023
Name of Agent: Phone No.:
I cerMy 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, if I should become subject to the workers compensation provisions Section 3700 of the
Labor Code, I II forthwith oompty with those provisions.
ig re of Applicanty 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:
CONTRACTOR'S DECLARATION:
rm under the penalty of Perjury that 1 am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Code, a`nd my license is i II force and effect.
_ ot)/03 0
r Signature Date
'NUMBER EXPIRATION DATE LICENSE TYPE (S)
750184 06/30/2024 C10, C46, C39, B