2501 E BALL RD (3)Permit Types
BLD ELE MEETPLM
X
Permit Number: BLD2023-02041
Issued: 05/23/2023
www.anaheim.neUbuilding
(714)765-4626
Quarter Section: 125
CITY OF ANAHEIM
BUILDING DMSION
200 S. ANAHEIM BLVD.
(714) 765 - 5153
Site Address: 2501 E BALL RD, ANAHEIM, CA 92806
Legal Description: S TWP 4 RGE 10 SEC 13 S 205 FT OF W 195 FT OF SE 1
APN:25307214
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:
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.
I 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 worker's Compensation insurance carrier and policy are:
Cartier. NATIONAL LIABILITY AND FIRE INSURANCE COMPANY Policy No.: SWC1414207 Expiration Date: 1212OL2023
Name of Agent: Phone No.:
1 certify that in the performance of the work for which this permit is issued, l shall not employ any person In any manner so as to become subject to the
workers compensation laws of Cali nd agree that, it I should become subject to the workefs compensation provisions of Section 3700 of the
Labor Code, all forthwith cowith ose provisions.
S gn ure of Ap i 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 WAViect.
Co ctorignatu Date
NUMBER EXPIRATION DATE LICENSE TYPE IS
1085633 01/31/2024 B, C36