115 S HARDING AVEPermit Types
BLD ELE MEC PLM
X
Permit Number: BLD2023-00424
Issued: 01/26/2023
www.anahejm.net/building
(714)765-4626
Quarter Section: 9
CITY OF ANAHEIM
BUILDING DIVISION
411,
200 S. ANAHEIM BLVD.
(714) 765 - 5153
Site Address: 115 S HARDING AVE A -C, ANAHEIM, CA 92804
Legal Description: N TR 403 BLK LOT 25 TR 403 LOT 25 POR OF LOT
APN:13528233
�KEWS COMPENSATION DECLARATION:
NTNG: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES
CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000); IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED
IN SECTION 3706 OR THE LABOR CODE. INTEREST, AND ATTORNEY'S FEES.
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. -
l I have and will maintain worker's
this permit is issued. My worker
Carrier: STATE COMPENS T
Name of Agent:
insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which
i insurance carrier and policy are:
Policy No.: 9021170 Expiration Date: 81=023
Phone No.:
I certify that in the perfo ace 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 Awf of Celifomia, and agree that, if I should become subject to the worker's compensation provisions of Section 3700 of the
Labor Code, I shall fo wI I
ply with those provisions.
Z
Signature of Applicant Date
DECLARATION REGARDING CONSTRUN LENDING AGENCY:
I hereby affirm under penalty of perjury that there 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 DE
1 hereby affirm under the penalty of Per
Professions Code, and my license is in
Contractor Signature
NUMBER
EXPIRATION DATE
i
I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the usiness and
e d effect.
� 2 20 23
Date
LICENSE TYPE ISI
652641 08/31/2024 C39, C39, C39, C39