2960 E JACKSON AVE (33)Permit Types
BLD ELE MEC PLM
X
Permit Number: BLD2023-01897
Issued: 04/21/2023
www.anaheim.nebbuilding
(714)765-4626
Quarter Section: 141
CITY OF ANAHEIM
BUILDING OMSION
200 S. ANAHEIM BLVD.
(714) 765 - 5153
Site Address: 2960 E JACKSON AVE, Anaheim, CA 92806
Legal Description: A TR GOLDEN STATE TR BLK 23 LOT 2 GOLDEN STATE TR
APN:26833207
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.
1 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 performance 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 permit is issued. My worker's Compensation insurance carrier and policy are:
Carrier: STATE COMPENSATION INSURANCE FUND Policy No.: 9255573 Expiration Date: 7/1@023
Name of Agent: Phone No.:
I certify that in the perfo an- 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 cempenseti aws o1 California, and agree that, if 1 should become subject to the workers compensation provisions of Section 3700 of the
Labor Code, I sh�l ith comply with those provisions.
Signature of
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:
Lender's Address:
LICENSED CONTRACTOR'S DECLARATION•
1 hereby affirm under the penalty of Perjury that I am 11 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 e
Contractor Signature
NUMBER
839467
EXPIRATION DATE
05/31/2024
LICENSE TYPE (S)
C39
Date