2125 W CHANTICLEER RDPermit Types
BLD ELE MEC PLM
X
Permit Number. BLD2023-01222°b .`
Issued: 03/14/2023
www.anaheim.net/building
(714)765-4626
Quarter Section: 42
CITY OF ANAHEIM
Site Address: 2125 W CHANTICLEER RD, ANAHEIM, CA 92804
Legal Description: N TR 6091 BLK LOT 15
APN: 12862431
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 - 5153
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 selfansure for worker's compensation, Issued by the Director of Industrial Relations as provided for by
Secion 3700 of the Labor Code, for the performance of the work for which this permit is issued.
J I have and will maintain worker's compensation insurance, as required by Seclion 3700 of the Labor Code, for the performance of the work for which
this permit is issued. My worker's Compensation insurance carder and policy are:
Cartier: STATE COMPENSATION INSURANCE FUND Policy No.: 1949902 Expiration Date: 12/1/2023
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
bor Co , I shall forthwith comply with those provisions. rr
Signa r of pljcan 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-provislons of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions an my license is in full force and offs
-p,6a3
Cont i natu Date
NUMBER EXPIRATION DATE LICENSE TYPE (S
956843 01/31/2025 C39
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