6199 E CAMINO CORRER (7)Permit Types
BLD ELE MEC PLM
X X X
Permit Number: BLD2022-05118
Issued: 12/06/2022
www.anaheim.net(building
(714)765-4626.
Quarter Section: 196
CITY OF ANAHEIM
Site Address: 6199 E CAMINO CORRERANAHEIM, CA 92807
Legal Description: N TR 7787 BLK LOT 21
APN:35813135
WORKER'S COMPENSATION DECLARATION:
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(7141 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 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 self -insure for worker's compensation, Issued by the Director of Industrial Relations as provided for by
w,section 3700 of the Labor Code, for the performance of the work for which this permit is Issued.
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 worker's Compensation insurance carrier and policy are:
Cartier: STATE COMPENSATION INSURANCE FUND Policy No.: 9268030 Expiration Date: 1/16/2023
Name of Agent: Phone No.:
— 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
er's compensation laws of California, and agree that, if I should become subject to the worker's compensation provisions of Section 3700 of the
bor Code, I all forthwith comply with those provisions.
Sigiiatijfe of 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 work for which this permit is Issued
(Sec.3097.Civ.C):
Lender's Name:
Lender's Address:
LICENSED CONTRACTOR'S DECLARATION:
1 herebyaffirm u he penalty of Perjury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions ode, d my Ilcense is n full force and effect.
FOnt&d6r Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE (S)
479446 10/31/2023 C53