1313 S EAST GATES STPermit Types
BLD ELE MEC PLM
X I X
Perms! Number: 2023-00321
Issued: 0211012023
www.anaheim.net/building
(714)765.4626
Quarter Section: 11
CITY OF ANAHEIM
Site Address: 1313 S EAST GATES ST, ANAHEIM, CA 92804
Legal Description: N TR 2264 BLK LOT 29
APN:07958408
WORKER'S COMPENSATION DECLARATION:
BUILDING DIVISION _
200 S. ANAHEIM BLVD. 4
(714) 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 selfansure 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.
r 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
/'r p the is permit is�su�e(d+.�My workers Compensatio�nQin�s(u�nce carrier end policy re:
GIeUnS'4a r: �OPgNo.: xpi► on at ` " J� n G
Name of Agent lOi 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
workers compensation laws of California, and agree that, If I should become subject to the workers compensation provisions of Section 3700 of the
Labor Code, I shall forthwith comply with those provisions.
Signature of Applica t Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
I hereby affirm under penalty of pedury 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 Pedury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force end effeet.
Contractor Signature
NUMBER EXPIRATION DATE LICENSE TYPE (S)
Date