755 S MELROSE STPermit Types .
BLD ELE MEC PLM
X
Permit Number: BLD2023-01764
Issued: 04/24/2023
www.anaheim.net/building
(714)765-4626
Quarter Section: 84
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(7141765.5153
Site Address: 755 S MELROSE ST, ANAHEIM, CA 92805
Legal Description: N TR 17077 BLK LOT 3 UN 27 TRACT 17077, LOT 3 OF P
APN: 93036078
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 (5100,600), 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 selfdnsure for worker's compensation, Issued by the Director of Industrial Relations as provided for by
MB 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. CLEAR SPRING PROPERTY AND CASUALTY COMPANY Policy No.: CWC00052001 Expiration Date: 7202023
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
Labor Code, I shall forthwith comply with those provisions.
Mehdi Bahrami 4/24/2023
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 1 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.
NATION ELECTRIC AND CONST 4/24/2023
Contractor Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE (S)
1005572 07/31/2023 C10, B
1242-g