2310 E LINCOLN AVE (6)Permit Types
BLDELE MECPLM
X
Permit Number: BLD2023-00620
Issued: 03/27/2023
www.anaheim.net/building
(714)765-0626
Quarter Section: 113
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765-5153
Site Address: 2310 E LINCOLN AVE, ANAHEIM, CA 92806
Legal Description: S TWP 4 RGE 10 SEC 12 T 4 R 10 SEC 12 POR SWI/4 -
APN: 08305114
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 worker's compensation insurance, as required by Section 3700 of the tabor Code, for the performance of the work for which
this permit Is issued. My worker's Compensation insurance carrier and policy are:
Cartier. TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA Policy No.: U85056580 Expiration Date: 1/112023
Name of Agent:
Phone No.:
1 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 1 should become subject to the worker's compensation provisions of Section 3700 of the
Labor Code, I with comply with those provisions.
Signature of Appl'
03 } Zs vj
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:
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.
Contractor Signet
NUMBER EXPIRATION DATE LICENSE TYPE IS
230077 01/31/2023 C10, 6, A
A; z-7AAPS-3
Date