3114 W MONROE AVE (2)Permit Types
BLD ELE MEC PLM
X
Permit Number:
Issued: 03/14/2023
www.anaheim.neUbuilding
(714)765-0626
Quarter Section: 8
Site Address: 3114 W MONROE AVE, Anaheim, CA 92801
Legal Description: N TR 1820 BLK LOT 104
APN: 13523317
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD. "
(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 affirm under penalty of perjury one of the following declarations:
I have and will maintain a certificate of consent to self4nsure 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.: 9216607 Expiration Date: SMS12023
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
alifornia, and agree that, If I should become subject to the worker's compensation provisions of Section 3700 of the
3m;�,,'Fply all with those provisions.
3-14-z:�s
Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
1 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:
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
Professlons Code, 4h0.mMicense [sip Nil force nd ftect.
Contractor
NUMBER
EXPIRATION DATE
LICENSE TYPE ISI
1030582 08/31/2023 C39
Date
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