1859 S JACALENE LNPermit Types
BLD ELE MEC PLM
X
Permit Number: BLD2023-00085
Issued: 01/10/2023
www.anaheim.net/building
(714)765-4626
Quarter Section: 67
Site Address: 1859 S JACALENE LN, Anaheim, CA 92802
Legal Description: N TR 3204 BLK LOT 71
APN:09060202
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 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 perfonnarice of the work for which this permit is issued.
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 perk is issued. My worker's Compensation insurance carrier and policy are:
Carrier. STATE COMPENSATION INSURANCE FUND Policy No.:31 00240 Expiration Date: 3/1/2023
Name of Agent: Phone No.:
I certify that in the performance of the work for which this peril is issued, l shall not employ any person in any manner so as to become subject to the
walker's compensatio laws of California, and agree that, if I should become subject to the worker's compensation provisions of Section 3700 of the
r Code, I shall rthwith comply with those provisions.
i l0 1z.3
Signature of 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:
Lender's Address:
LICENSED CONTRACTOR'S DECLARATION:
I hereby affirm under the penalty of Perjury that 1 am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions Code, nd my lice nse is ' full force and effect
Contractor Signature
NUMBER EXPIRATION DATE LICENSE TYPE (S)
524341 06/30/2022 C39
1412
Date