1765 N COMMUNITY DR (3)PermitPermit Types.��
BLD ELE MEC FLM
X
Permit Number. BLD2022-04679
Issued: 10/03/2022
www.anaheim.net/building
(714)765.4626
Quarter Section:130
CITY OF ANAHEIM
Site Address: 1765 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.
(714) 765.5153
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 3700 OR THE LABOR CODE. INTEREST, AND ATTORNEY'S FEES.
I hereby affirm under penalty of perjury one of the following declarations:
1 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.
1 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 workers Compensation insurance carrier and policy are:
Cartier. STATE COMPENSATION INSURANCE FUND Policy No.: 9081874 Expiration Date: 12/17/2022
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
wo mpens; -on laws Cali la, and agree that, if I should become subject to the workers compensation provisions of Section 3700 of the
bor e,1 shall forth wf with those provisions.
Sr o 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 wo* for which this permit Is Issued
(Sec.3097.Civ.C):
Lender's Name:
Lenders Address:
LICENSED CONTRACTOR'S DELL
1 hereby affirm a tty of Perjury
s
Prole Codna
e, and y license is in full i
Signature
NUMBER EXPIRATION DATE
989741 01/31/2024
under provisions of chapter 9 (commencing with Section 7000) of DMsion 3 of the Business and
LICENSE TYPE ISl
C39
Date