123 E ELLSWORTH AVE (2)Permit Types
BLD ELE MEC PLM
X X X
Permit Number: BLD2022-05244
Issued: 05/18/2023
www.anaheim.net/building
(714)765-0626
Quarter Section: 84
CITY OF ANAHEIM
BUILDING DMSION
200 S. ANAHEIM BLVD.
(7141 765 - 5153
Site Address: 123 E ELLSWORTH AVE, ANAHEIM, CA 92805
Legal Description: N TR 497 BLK LOT 7 TR 497 LOT 7 POR OF LOT AND LOT
APN: 25108414
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 worker's compensation, Issued by the Director of Industrial Relations as provided for by
p 1 Section 3700 of the Labor Code, for the performance of the work for which this permit is issued.
e (J rm
1 have and will maintain workers compensation insurance, as required by Section 3700 of the labor Code, for the perfoance of the work for which
(J this permit is issued. My worker's Compensation insurance carrier and policy are:
Cartier: LM INSURANCE CORPORATION Policy No.: WA561DBBTSZ6013 Expiration Date:11112024
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
worker's compensation laws of California, and agree that, 01 should become subject to the worker's compensatian provisions of Section 3700 of the
Labor Code, I shall forthwith comply with those provisions.
AAM rA Z��s
S gna u of nt 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, qnd my license is In full force and effect.
on ctor Signature
NUMBER EXPIRATION DATE LICENSE TYPE ISl
671513 05/3112023 A. A, C10, C10, B, B, HAZ, HAZ
Date