980 S HARVARD CIRPermit Types
BLD ELE MEC PLM
X
Permit Number: BLD2023-0024V
Issued: 01/18/2023
www.anaheim.net/building
(714)765-4626
Quarter Section: 287
Site Address: 980 S HARVARD CIR, ANAHEIM, CA 92807
Legal Description: N TR 8375 BLK LOT 96
APN:36508320
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 ATTORNEYS FEES.
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certificate of consent to self4nsure for worker's compensation, issued by the Director of Industrial Relations as provided for by
n r, Section 3700 of the Labor Code, for the performance of the work for which this permit is issued.
�1 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
thi emit is issued. My worker's Compensation insurance cerier and policy are:
p Cam :OLD REPUBLIC INSURANCE COMPANY Policy No.: MWC314156 Expiration Date: 10/1/2023
II Name f Agent: Phone No.:
I certify Pat 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 compensation laws of California, and agree that, if I should become subject to the workers compensation provisions of Section 3700 of the
Labor C de, I shall forthwith comply with those provisions.
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):
Lenders Name:
Lenders Address:
LICE SED NTRACTOR'S DECLARATION:
I here y affirm u der the penalty of Perjury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Profs I ns Cod , a my license is in full force and effect
" /0'-2-3
Contractor Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE (SI
990416 07/31/2023 B. C17