1447 N BUCKINGHAM ST (2)Permit Types
BLD ELE MEC PLM
X X
Permit Number: BLD2022-05045
Issued: 12/06/2022
www.anaheim.net/building
(714)765-4626
Quarter Section: 23
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(7141 765 - 5153
Site Address: 1447 N BUCKINGHAM ST, ANAHEIM, CA 92801
Legal Description: N TR 2358 BLK LOT 11 TR NO 2358 LOT 11 POR OF LOT
APN:07135145
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 tabor Code, for the performance of the work for which
this permit is issued. My worker's Compensation insurance carder and policy are:
Cartier: AMERISURE MUTUAL INSURANCE COMPANY Policy No.: =21114540302 Expiration Date: 4/1/2023
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, and agree that, if 1 should become subject to the worker's compensation provisions of Section 3700 of the
Labor Code, I shall forthwith comply with those provisions.
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nature 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 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.
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CoqWctor Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE (Si
1062072 01/31/2024 C46, C70