1853 W KATELLA AVE (3)Permit Types
BLD ELE MEC PLM
X
Permit Number: BLD2022-04479
Issued: 09/20/2022
www.anaheim.net/building
(714)765-4626
Quarter Section: 50
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 - 5153
Site Address: 1853 W KATELLA AVE, ANAHEIM, CA 92804
Legal Description: S TWP 4 RGE 10 SEC 20 SEC 20 T 4 R 10 S 200 FT E 9
APN:12856131
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 ($700,000), 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 perjury one of time 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.
%C I have and will maintain workers compensation insurance, as required by Section 3700 of the labor Code, for the performance of the work for which
this permit is issued. My workers Compensation insurance carter and policy are:
Cartier. STATE COMPENSATION INSURANCE FUND Policy No.: 1949902 Expiration Date: 12/1/2022
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 became subject to the worker's compensation provisions of Section 3700 of the
Labor ode, I shall forthwith comply with those provisions.
Signet ofp Icant
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
Date
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):
Lender's Name:
Lendees 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, anA'my license is in full force
NUMBER EXPIRATION DATE
956843 01/31/2023
LICENSE TYPE (S)
C39
Date