1133 S CHANTILLY STPermit Types
BLO ELE MEC PLM
X
Permit Number: BLD2023-00230
Issued: 01/20/2023
www.anaheim.neUbuilding
(714)765-4626
Quarter Section: 125
ookinc
CIN OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD. r
(714)765-5153
Site Address: 1133 S CHANTILLY ST, ANAHEIM, CA 92806
Legal Description: N TR 4716 BLK LOT 33 Y
APN: 25342113
F k/
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 self4nsure for worker's compensation, issued by the Director of Industrial Relations as provided for by
PJ 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. NORGUARD INSURANCE COMPANY Policy No.: APWC328074 Expiration Date:0 61 / /2023
Name of Agent
Phone No.:
I 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
worker's compensation laws of California, and agree that, if I should become subject to the worker's compensation provisions of Section 3700 of the
Labor Code, l shall forthwith comply with those provisions.
Pablo J Gonzalez 1/20/2023
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:
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 and effect.
A P J V ELECTRIC INC
Contractor Signature
NUMBER EXPIRATION DATE LICENSE TYPE (S)
969955 04/30/2022 C10
Date
1/20/2023