1617 W CRONE AVEPermit Types
BLD I ELE I MEC PLM
X X X X
Permit Number. BLD2022-05245
Issued: 05/02/2023
www.anaheim.net/building
(714)765-4626
Quarter Section: 55
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 - 5153
Site Address: 1617 W CRONE AVE, ANAHEIM, CA 92802
Legal Description: A TR ANAHEIM INVESTMENT CO TR BLK LOT 10 ANAHEIM I
APN: 25008219
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
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: LM INSURANCE CORPORATION Policy No.: WA561DBOTOZ6013 Expiration Date: 1/11=
Name of Agent: Phone No.:
I car* 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
worker's compensation laws of California, and agree that, if I should become subject to the workers compensation provisions of Section 3700 of the
Labor Code, I shall forthwith comply with those provisions.
i.n.t re o Ap cant
Oat
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):
Lenders Name:
Lenders Address:
LICENSED CONTRACTOR'S DECLARATION:
I hereby affirm under the penalty of Pedury that I am licensed under provlslons 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.
C ntractor Sign
NUMBER EXPIRATION DATE
671513 05/31/2023
5/:Z /�
Date
LICENSE TYPE IS
A. A. A. C10, C10, C10, B. S. B. HAZ, HAZ, HAZ