2063 W CORONET AVE (6)Permit Types
BLD ELE MEC PLM
X
Permit Number: BLD2023-00837'
Issued: 02/21/2023
www.anaheim.net/building
(714)765.4626
Quarter Section: 37
CITY OF ANAHEIM
e t' BUILDING DMSION
200 S. ANAHEIM BLVD.
(714) 765.5153
Site Address: 2063 W CORONET AVE, ANAHEIM, CA 92801
Legal Description: N TR 2197 BLK LOT 6
APN:07230106
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:
1 have and will maintain a certificate of consent to selfansure 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 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.:39 08639 Expiration Date: 11/11/2023
Name of Agent: Phone No.:
I 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
workers compensation laws of California, and agree that, if I should become subject to the workers compensation provisions of Section 3700 of the
Lebo de, I shall forthwith comply with those provisions.
`Signature o Applicant
Zz
Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
I hereby affirm under penalty of pedury that there is a construction fending 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 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.
Contras orKnalul',-�—
NUMBER EXPIRATION DATE LICENSE TYPE IS
1088759 03/31/2024 C39
S/
Zl 2
Date
, .:,1 [",