5245 E GERDA DR (4)Permit Types
BLD ELE MEC PLM
X X
Permit Number. BLi 340211`=—w
Issued: 02/16/2023
www.anaheim.net/building
(714)765-4626
Quarter Section: 179
Site Address: 5245 E GERDA DR, ANAHEIM, CA 92807
Legal Description: N TR 4958 BLK LOT 73
APN: 35802202
WORKER'S COMPENSATION DECLARATION:
CITY OF ANAHEIM
BUILDING DMSION
200 S. ANAHEIM BLVD.
(7141765-5153
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.
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certificate of consent to selMnsure 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. STATE COMPENSATION INSURANCE FUND Policy No.: 9078830 Expiration Date: 71/2/2020
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 person in any manner so as to become subject to the
worker's compensation laws of California, and agree that, if I should become subject to the worker's compensation provisions of Section 3700 of the
Labor Code, I shall forthwith comply with those provisions.
iq
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:
I hereby affirm under the penalty of Perjury that I am licensed under provisions of chapter 9 (commencing with Section 70001 of Division 3 of tho Rusinnan and
Professions Co e, and my license Is in II force and effect.
Contractor Signature
NUMBER EXPIRATION DATE LICENSE TYPE (Sl
976687 11/30/2022 C10
0Z?L0�3
Date