2125 E LINCOLN AVEPermit Types
BLD I ELE I MEC I PLM
X I X I X I X
Permit Number. OLD202245773
Issued: 03/29/2023
www.anaheim.net/building
(714)765-4626
Quarter Section:113
CITY OF ANAHEIM
BUILDING OMSION
200 S. ANAHEIM BLVD.
(714) 765.5153
Site Address: 2125 E LINCOLN AVE, ANAHEIM, CA 92806
Legal Description: S TWP 4 RGE 10 SEC 12 T 4 R 10 SEC 12 POR OF SW 1/
APN: 08334420
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 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 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 carrier and policy are:
Cartier. STATE COMPENSATION U Policy No.: 9296732 Expiration Date: 211612024
Name of Agent: Phone No.: 39
I certify that in the performance 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 compensation laws of California, and agree that, if I should become subject to the workers compensation provisions of Section 3700 of the
Labor Code, I shall forthwith comply with those provisions.
Signatureof Appl' nt
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
(--�/29I23
Date
I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work for which this perm Is Issued
(Sec.3097.Civ.C):
Lenders 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
Professions Code, and my license Is in full force and effect.
Contra cto ig ature
6
NUMBER EXPIRATION DATE LICENSE TYPE (Sl
1053661 05/3112023
Date