5515 E LA PALMA AVE (28)Permit Types
BLD ELE MEC PLM
X X X X
Permit Number: BLD2022-04719
Issued: 01/10/2023
www.anaheim.nebbuilding
(714)765-4626
Quarter Section: 178
CITY OF ANAHEIM
Site Address: 5515 E LA PALMA AVE 102, ANAHEIM, CA 92807
Legal Description: P BK 287 PG 17 PAR 2
APN: 34627114
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(7141 765 - 5153
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 selfninsure 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. STATE COMPENSATION INSURANCE FUND Policy No.:09 36265 Expiration Date: 1211112022
Name of Agent.
Phone No.:
I certify at 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
' co p
sell
laws of California, and agree that, it I should become subject to the worker's compensation provisions of Section 3700 of the'
Lear de, I sh II forthwith comply with those provisions.
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lea
Signa of Appin 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 affi n fy of Perjury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Prof ons Co , a y Il se is in full force and effect.
Con rector SiinattM Date
NUMBER EXPIRATION DATE LICENSE TYPE (S)
669342 10131t2022