2787 W CORNELL PL (3)Permit Types
BLD ELE MEC PLM
X X X X
Perrult Number: BLD202245008
Issued: 05/02/2023
www.anaheim.net/building
(714)765-4626
Quarter Section: 19
Site Address: 2787 W CORNELL PL, Anaheim, CA 92801
Legal Description: N TR 3045 BLK LOT 29
APN:07063208
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(7141765-5153
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.
1 hereby affirm under penalty of pedury 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
J Section 3700 of the Labor Code, for the performance of the work for which this permit is issued.
1! 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.: 9335935 Expiration Date: 411/2024
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 Celifomia, and agree that, if 1 should become subject to the workers compensation provisions of Section 3700 of the
Labor Code, I shall forthwit h oom ly with those provisions.
Signature of Applicant Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
I hereby affirm under penalty of perjury that there Is a construction tending agency for the performance of the work for which this permit Is issued
(Sec.3097.Civ.C):
Lenders Name:
Lenders Address:
LICENSED CONTRACTOR'S DECLARATION:
I hereby affirm under the penally of Perjury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions Cade, and my license is in full force and effect.
Contractor Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE (S)
950477 07131/2024 A. B