1201 N MOSSWOOD DRPermit Types
BLD ELE MEC PLM
X
Permit Number.'BLD2023-00361
Issued: 03/10/2023
www.anaheim.net/building
(714)765-4626
Quarter Section: 200
CITY OF ANAHEIM
Site Address: 1201 N MOSSWOOD DR, ANAHEIM, CA 92807
Legal Description: N TR 7417 BLK LOT 23
APN:35106128
00S,
MPING DM ON _
00 S ANAHEIM LVD.
(714) 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 arum under penalty of pedury 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 worker's Compensation Insurance carrier and policy are:
Carrier. STATE COMPENSATION INSURANCE FUND Policy No.: 9127223 Expiration Date: 311512024
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 fo with comply with se provis
I �- V — zjL'
SI ,le of Applican 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 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 fo and effect.
C
4rajor Sig a ure
NUMBER EXPIRATION DATE LICENSE TYPE ISl
547397 06/30/2023
�W V Zo'zL523
Date