3370 E LA PALMA AVE (5)Permit Types
PBLD ELE MEC PLM
X
Permit Number: OLD2022-04677
Issued: 10/03/2022
www.anaheim.nef/building
(714)765.4626
Quarter Section: 145
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 - 5153
Site Address: 3370 E LA PALMA AVE, ANAHEIM, CA 92806
Legal Description: A TR ORANGE GROVE ACRES BLK LOT 6 ORANGE GROVE ACR
APN: 34512102
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 ATTORNEYPS 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.
O/ 1 have and will maintain workers compensation Insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which
(C this permit is issued. My workers Compensation insurance carrier and policy are:
Cartier. Policy No.: GLSISTC002067722 Expiration Date: 5/27/2023
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
worker's compen tion laws of California, and agree that, 01 should become subject to the workers compensation provisions of Section 3700 of the
Labor Code, all forthwith comply with those provisions.
1 1/1/0__?%2 7
SignatureAp lica Date r
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:
1 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 m 4'oense is in full force and effect.
r'0 a 2
Contrac� or Sig atu Date
NUMBER EXPIRATION DATE LICENSE TYPE ISl
1057026 08/31/2023 C10