203 S HACIENDA ST (2)Permit Types
BLD ELE MEC PLM
X
Permit Number: OLD2023-01541
Issued: 04/03/2023
www.anaheim.net/building
(714)765.4626
Quarter Section: 47
Site Address: 203 S HACIENDA ST, ANAHEIM, CA 92804
Legal Description: N TR 2995 BLK LOT 56
APN: 12806401
CITY OF ANAHEIM
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 penalty of perjury one of the following declarations:
I have and will maintain a certificate of consent to selfansure 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.
Alr� I have and will maintain worker's compensation Insurance, as required by Section 3700 of the tabor Code, for the performance of the work for which
O7� this permit is issued. My workers Compensation insurance carrier and policy are:
Cartier. SIRIUS AMERICA INSURANCE COMPANY Policy No.: 1W8517001 Expiration Date:1?14/2023
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 person In any manner so as to become subject to the'
workers compensation laws of California, and agree that, H I should become subject to the worker's compensation provisions of Section 3700 of the
bor Code, I shall forthwith comply with those provisions.
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IMP
Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
l 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:
Lender's 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 Division 3 of the Business and
Protessio e, end my license is in full force and effect.
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NUMBER EXPIRATION DATE LICENSE TYPE (Sl
962785 03/31/2022 C10
V3 Z®Z3 - -
Date