2136 E CENTER STPermit Types ,
BLD ELE MEC PLM
X
Permit Number: BLD2022-04522
Issued: 09/22/2022
www.anaheim.net/building
(714)765-0626
Quarter Section: 112
Site Address: 2136 E CENTER ST, ANAHEIM, CA 92806
Legal Description: N TR 1843 BLK LOT 57
APN:08334208
CITY OF ANAHEIM
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 ATTORNEYS FEES.
I hereby affirm under penalty of pedury one of the following declarations:
I have and wiil maintain a certificate of consent to self -Insure for workers compensation, issued by the Director of Industrial Relations as provided for by
r 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. NORGUARD INSURANCE COMPANY Policy No.: HDWC326717 Expiration Date: 412112023
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
Labor Code, l shall forthwith comply with those provisions.
----S1gffr of ApIticdnt 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:
1 hereby affirm under the penalty of Perjury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my It s is in full force and effect.
Contractor gnat re
NUMBER EXPIRATION DATE LICENSE TYPE IS)
1040915 06/30/2024 B. C27
002/7-&/ao 22
Date