954 S SCANYON HEIGHTS DR (2)Permit Types
BLD ELE MECPLM
X X
Permit Number. BLD2023-01935
Issued: 04/24/2023
www.anaheim.nef/building
(714)7654626
Quarter Section: 232
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
1714) 765.5153
Site Address: 954 S CANYON HEIGHTS DR, ANAHEIM, CA 92808
Legal Description: N TR 15123 BLK LOT 18
APN:51408106
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 ($700,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED
FOR IN SECTION 3706 OR THE LABOR CODE. INTEREST, AND ATTORNEYS 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 wtdch
this permit is Issued. My workers Compensation insurance carrier and policy are:
Cartier. NATIONAL LIABILITY AND FIRE INSURANCE COMPANY Policy No.: N9WC942134 Expiration Date: 1/14/2024
Name of Agent: Phone No.:
1 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
workers compensation taws of California, and agree that, N I should become subject to the workers compensation provisions of Section 3700 of the
Labor Code, I shall f comply with those provisions.
o
Signature n 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 0 se Is in full force and effect.
Contractor Ignat Date
NUMBER EXPIRATION DATE LICENSE TYPE (S)
1056600 08/31/2023