129 S GLENDON ST (5)Permit Types
BLD ELE MEC PLM
X X
Permit Number. BLD2023-01639
Issued: 05/17/2023
www.anaheim.net/building
(714)7654626
Quarter Section: 134
Site Address: 129 S GLENDON ST, ANAHEIM, CA 92806
Legal Description: N TR 4412 BLK LOT 24
APN:26805206
WORKER'S COMPENSATION DECLARATION:
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(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.
1 hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certificate of consent to selfminsure 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 workers 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 ere:
Cartier: STATE COMPENSATION INSURANCE FUND Policy No.: 9235935 Expiration Date: 8/9/2023
Name of Agent: Phone No.:
I certify that in the performance of the work for which this permit Is issued, l shall not employ any penton in any manner so as to become subject to the
workers compensation laws of California, and agree that, 91 should become subject to the worker's compensation provisions of Section 3700 of the
Labor Code, I shall forthwith comply with those provisions.
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):
Lender's Name:
Lenders 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 DMsion 3 of the Business and
Professions Code, and my license Is in full force and effect.
Contractor Signature
NUMBER EXPIRATION DATE LICENSE TYPE (S)
1045016 09/3012022 C46, B. C10
57 A O
Date