1580 S DISNEYLAND DR (36)Permit Types
BLD ELE MEC PLM
X X X X
Permit Number: BLD2022-05901
Issued: 04/18/2023
www.anaheim.netlbuilding
(714)765-4626
Quarter Section: 76
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(7141 765 - 5153
Site Address: 1580 S DISNEYLAND DR 106, ANAHEIM, CA 92802
Legal Description: S TWP 4 RGE 10 SEC 22 T4 R10 SEC 22 POR OF W 1/2
APN:08219027
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 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
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: STATE COMPENSATION INSURANCE FUND Policy No.: 9022708 Expiration Date: 911f2023
Name of Agent Phone No.:
I ce' 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
A- cam sation laws of California, and agree that, if I should become subject to the workers compensation provisions of Section 3700 of the
Lob Cc , shall forthwith comply with those provisions.
17
nature 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):
Lenders Name:
Lenders Address:
LICENSED CONTRACTOR'S DECLARATION:
I hereby attire under the pe of Perjury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions Cc e, an y license Is In full force and effect.
Z3
rector Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE IS)
816820 04/30/2024 B. B