1734 S HEATHER LNPermit Types
BLD ELE MEC PLM
X
Permit Number. BLD2023-02479
Issued: 05/19/2023
www.anaheim.net/building
(714)765.4626
Quarter Section: 66
Site Address: 1734 S HEATHER LN, Anaheim, CA 92802
Legal Description: N TR 2180 BLK LOT 39
APN: 12942403
WORKER'S COMPENSATION DECLARATION:
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 -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 ATTORNEYS FEES.
1 hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certificate of consent to selfinsure for workers 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 workers compensation insurance, as required by Section 3700 of the tabor Code, for the performance of the work for which
this permit is Issued. My workers Compensation insurance carrier and policy are:
Carrier. STATE COMPENSATION INSURANCE FUND Policy No.: 1949902 Expiration Date: 1211/2023
Name of Agent. Phone No.:
I certify that 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
workers compensation laws of California, and agree that, If I should become subject to the workers compensation provisions of Section 3700 of the
Labor Code, I shall forthwith comp th those provisions.
Signa tu Ap 1lcant Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
I hereby affirm under penally 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 Cods, *d my license Is in full forse and effect
EXPIRATION DATE
956843 01/31/2025
C39
Date