996 S CITRON STPermit Types
BLD ELE MEC PLM
X
Perinit 'lumber: BLD2023-01220
Issued: 03/14/2023
www.anaheim.net/building
(714)765-0626
Quarter Section: 74
CITY OF ANAHEIM
11UILDINIVISION
200 S. AN DAHEIM BLVD.
(7141 765 - 5153
Site Address: 996 S CITRON ST, ANAHEIM, CA 92805
Legal Description: N TR 10954 BLK LOT 1 UN 37 TR 10954 LOT 1 UNIT 37
APN: 93823037
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 selfainsure 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: ACE AMERICAN INSURANCE COMPANY Policy No.: WLRC50668150 Expiration Date: 3/1/2024
Name of Agent:
Phone No.:
I certify m 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
wa is compensation laws of California, and agree that, if I should become subject to the worker's compensation provisions of Section 3700 of the
or de, I shall f th p with those provisions.
4or-6
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:
Lenders Address:
LICENSED CONTRACTOR'S DECLARATION:
I hereby affirm un a penalty of Perjury that 1 am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions de,W7Wd effect.
Contractor Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE (S)
602331 09/30/2024 C10, B. D12, C-2, C39, C-6, C17, C36, D34, D41, D24
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