1327 E LA PALMA AVEPermit Types .
BLD I ELE I MEC I PLM
X I __x I I X
Permit Number: BLD2023-00448
Issued: 01/27/2023
www.anaheim.net/building
(714)765.4626
Quarter Section: 91
CITY OF ANAHEIM
BUILDING DMSION
200 S. ANAHEIM AVD.
(7141 765 -5153
Site Address: 1327 E LA PALMA AVE, ANAHEIM, CA 92805
Legal Description: S TWP 4 RGE 10 SEC 2 SEC 2 T 4 R 10 POR SW1/4 SWI/
APN:07340616
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.
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certificate of consent to selfoinsure 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:
Cartier: Policy No.: Expiration Date:
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
worker's compensation laws of California, and agree that, if I should become subject to the worker's compF-)0-T Section 3700 of the
Labor Code, I shall forthwith comply with those provisions.
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Signature of icant 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:
[rR]n 140
,CTOR'S DECLARATION:
penalty of Perjury that I am licensed under provisions of chapter 9 (commencing with Section 70 0) of Divisl 3 of the Business and
iy license is in full force and effect.
2-3
Date
EXPIRATION DATE
947404 07/3112023 B, ASB
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