1430 E DELTA PLPermit Types
BLD ELE MEC PLM
X X
Permit Number: BLDZGi3-0051$
Issued: 02/22/2023
www.anaheim.net/building
(714)765-4626
Quarter Section: 104
Site Address: 1430 E DELTA PL, ANAHEIM, CA 92805
Legal Description: N TR 3397 BLK LOT 36
APN: 08252205
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 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
A J 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 worker's Compensation insurance carrier and policy are:
Cartier. STATE COMPENSATION INSURANCE FUND Policy No.:39 06867 Expiration Dale: IDIN023
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 penton in any manner so as to become subject to the
worktpignpensaflon laws of California, and agree that, if 1 should become subject to the worker's compensation provisions of Section 3700 of the
r e, I shall forthwi reply with those provisions.
2- zz--Z.>
Signature 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:
Lenders Address:
LICENSED CONTRACTOR'S DECLARATION:
I hereby afti er th natty of Perjury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Profs ssio Code, and y license is in full force and effect.
2 -2,7 -
Contractor Signature
NUMBER EXPIRATION DATE LICENSE TYPE IS)
1038376 04/30/2022 B, C39, C10, A
Date