1939 W BROADWAY (3)Permit Types - -
BLD ELE MEC PLM
X
Permit Number. OLD2023-02085
Issued: 05/01/2023
www.anaheim.net/buiiding
(714)765.4626
Quarter Section: 40
Site Address: 1939 W BROADWAYANAHEIM, CA 92804
Legal Description: N TR 2299 BLK LOT 324
APN:12804508
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 seif4nsure 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 pemrit 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:
Cartier. Policy No.: Expiration Date:
Name of Agent: - Phone No.:
r) I certify that in the performance of the work for which this pemtit is issued, I shall not employ any person In any manner so as to become subject to the
,1Porkees compensation laws of California, and agree that, I I should become subject to the workers compensation provisions of Section 3700 of the
60r6 e,1 shall forthwith comply with those provisions.
Signature of Applica 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:
Lenders Address:
LICENSED CONTRACTOR'S DECLARATION:
1 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
saran i se is in hill force and effect
Contractor Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE (S)
921195 08/31/2024