928 S FANN ST (3)Permit Types
BLD ELE MEC PLM
X
Permit Number: BLD2022-05149
Issued: 12/01/2022
www.anaheim.net/buiiding
(714)765.4626
Quarter Section: 48
Site Address: 928 S FANN ST, ANAHEIM, CA 92804
Legal Description: N TR 2377 BLK LOT 25
APN:12826407
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 self4nsure 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 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:
Carrier. CYPRESS INSURANCE COMPANY Policy No.: ATWC345014 Expiration Date: 11111512023
Name of Agent: i 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 sy
worker's compensation laws of California, and agree that, if i should become subject to the workers compensation provisions of Section 3700 of the
Lor Code, I shall forthwith comply with those provisions.
Labor .
/2-r -ZZ
Signa of Applicant Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
---I herebyaffirm-under penaltyof perjury that there Is a construegondendingagency-for-the pedermance•of4he work -for -which this permit Is Issued
(Sec.3097.Civ.C):
Lender's Name:
Lender's Address:
LICENSED CONTRACTOR'S DECLARATION:
I hereby affirm under the penalty of Perjury that 1 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 and effect.
Contractor nature
NUMBER EXPIRATION DATE LICENSE TYPE ISI
572282 07/31/2023
12 -t -ZZ
Date