1755 N COMMUNITY DR (3)Permit Types ..
BLD ELE MEC PLM
X
Permit Number: BLD2022-04680
Issued: 10/03/2022
www.gnaheim.net/building
(714)765.4626
Quarter Section: 130
CITY OF ANAHEIM
Site Address: 1755 N COMMUNITY DR, Anaheim, CA 92806
Legal Description: N TR 613 BLK A TR 613 LOT A POR OF LOT
APN:33908111
WORKER'S COMPENSATION DECLARATION:
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(7141765-5153
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 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 workers 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 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. STATE COMPENSATION INSURANCE FUND Policy No.: 9081874 Expiration Date: 12102022
Name of Agent:
Phone No. -
1 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
workers compensation laws of Califople, and agree that, t I should become subject to the workers compensation provisions of Section 3700 of the
or Cod , I shall foo"Ith p th those provisions.
/0-3•oZ�
Signatu Applicant Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
1 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 1 i I nsed under provisions of chapter 9 (commencing with Section 7000) of DMsion 3 of the Business and
Professions Code, cense Is in full e .
Contracto ignature
Date
NUMBER EXPIRATION DATE LICENSE TYPE (Sl
989741 01/31/2024 C39