3104 E FRONTERA ST (2)Permit Types
BLD ELE MEC PLM.
X
Permit Number: BLD2022-05364
Issued: 04/10/2023
www.anaheim.net/building
(714)765-4626
Quarter Section: 146
CITY OF ANAHEIM
Site Address: 3104 E FRONTERA ST, ANAHEIM, CA 92806
Legal Description: P BK 227 PG 25 PAR 1
APN: 36006115
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 penally 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 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: TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA Policy No.: UB9R6469822226G Expiration Date: 42023
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, if I should became subject to the workers compensation provisions of Section 3700 of the
Labor Code, I shag forthwith comply with those provisions.
Aff&92, K' 04/10/2023
Signature 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 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
Pmfesslcns Code, and my license is in full force and effect.
Contractor Signature)
NUMBER EXPIRATION DATE LICENSE TYPE (S)
1075291 04/30/2023
04/10/2023
Date