1325 S EUCLID ST (2)Permit Types
BLD ELE MEC PLM
X X X X
Permit Number. BLD2022-06174
Issued: 05/04/2023
wwmanaheim.nebbuilding
(714)765.4626
Quarter Section: 49
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 - 5153
Site Address: 1325 S EUCLID Street, Anaheim, CA 92802
Legal Description: N TR 2779 BLK LOT 140 TR 2779 LOT 140 ALL -EX ST-
APN:12838414
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 ceAificate of consent to selfdnsum for worker's compensation, issued by the Director of Industrial Relations as provided for by
�7 Section 3700 of the labor Code, for the performance of Ore work for which this permit is issued.
1}/ `��/ 1 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. SIRIUS AMERICA INSURANCE COMPANY Policy No.: WC6736601 Expiration Date: 12131=23
Name of Agent: Phone No.:
I ceRify 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
workee mpensation laws of California, and agree that, if 1 should become subject to the workers compensation provisions of Section 3700 of the
r Code, I shall torthwit h comply with those provisions.
Signature of Applicant Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
I hereby affirm under penally 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:
1 hereby affirm der the penalty of Perjury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Profession de and my license is in force and effect.
Contractor Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE (S1
960577 05/3112023