1655 W LINCOLN AVEPermit Types
BLD ELE . MEC PLM
X I X
Permit Number. BLD2023-01553
Issued: 04/05/2023
www.anaheim.net/building
(714)765.4626
Quarter Section: 53
CITY OF ANAHEIM
BUILDING DnnSION
200 S. ANAHEIM BLVD.
1714) 765- 5153
Site Address: 1655 W LINCOLN AVE, Anaheim, CA 92801
Legal Description: N TR 19017 BLK LOT 1 UN HOLD POR OF LOT 1 OF TRACT
APN: 07211056
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
\/ QD Section 3700 of the Labor Code, for the performance of the work for which this permit is issued.
T —Jt�J 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
V pts this permit is issued. My workers Compensation insurance carrier and policy are:
Carrier. OLD.REPUBLIC INSURANCE COMPANY Policy No.: MWC31414822 Expiration Date: 9/1/2023
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
r Co , II f th comply with those provisions.
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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):
Lender's Name:
Lender's 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
PTonse, end myn full force and effect.
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Contractor Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE (S)
728102 04/30/2024