2655 W GREENLEAF AVE (2)Permit Types
BLD ELE MEC PLM
X
Permit Number: BLD202245490
Issued: 11/17/2022
www.anaheim.neUbuilding
(714)765.4626
Quarter Section: 18
CITY OF ANAHEIM
Site Address: 2655 W GREENLEAF AVE, ANAHEIM, CA 92801
Legal Description: N TR 2332 BLK LOT 92
APN: 07027415
BUILDING DMSION
200 S. ANAHEIM BLVD.
(7141765- 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 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:
Cartier. STATE COMPENSATION INSURANCE FUND Policy No.: 9305262 Expiration Date: 9/11/2023
Name of Agent . T - '^tI D 01J Phone No.: 11'-5 ZSZ
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 sation laws of California, and agree that, if I should become subject to the worker's compensation provisions of Section 3700 of the
L r Code, I I forthwith comply with those provisions.
Signature of Applicant Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
I hereby affirm under penalty of perjury that thereis 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:
I hereby affirm under the penal Perjury that 1 am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions Code, and cense is in hull force and effect.
Contractor Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE (S)
1083975 11/30/2023 C39