184 W CENTER STPermit Types
BLD ELE M
EC PLM
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Permit Number. 80211T1G0'J
Issued: 03/02/2023
www.anaheim.net(building
(714)765.4626
Quarter Section: 83
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 - 5153
Site Address: 184 W CENTER STREET PROMENADEANAHEIM, CA 92805
Legal Description: N TR 17251 BLK LOT 3
APN:03701502
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 self4nsure for workers compensation, issued by the Director of Industrial Relations as provided for by
Q 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:
Cartier. STARNET INSURANCE COMPANY Policy No.: SNUWC0159031 Expiration bate: lHsn024
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
work laws of California, and agree that, if I should become subject to the workers compensation provisions of Section 3700 of the
rbttCode, I shall forth tit comply with those provisions.
Signature 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:
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
Professions *,, and in Ifect.
Contractor Signature
NUMBER EXPIRATION DATE LICENSE TYPE (S)
-
1046239 10/31/2024
�-Z- 2 3 -
Date
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