832 S HELENA ST (2)Permit Types
BLD ELE MEC PLM
X
'"rs errAl'Nutnber: BLD2023-01067
Issued: 03/06/2023
Www.anaheim.net/building
(714)765-0626
Quarter Section: 74
Site Address: 832 S HELENA ST, ANAHEIM, CA 92805
Legal Description: N TR 1392 BLK LOT 7
APN:03626207
CITY OF ANAHEIM
BUILDING DIVISION -
200 S. ANAH&A BLVD.
(714) 765 - 5153
WORIMITS COMPENSATION DECLARATION:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES
AND CML 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 pedury one of the following declarations:
1 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.
AtA 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.: 9330593 Expiration Date: 12(3012023
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.
MSI e& 03 -0(P -?r3
Signature of Applican Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
1 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 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect.
ntractor Signature
NUMBER EXPIRATION DATE LICENSE TYPE (S)
1023239 01/3112025 C39
03r -oto - 2i ,
Date