1320 S ORIOLE ST (3)Permit Types
BLD ELE MEC PLM
X X
Permit Number: BLD2023-00645^
Issued: 03/07/2023
www.anaheim.net/building
(714)765-0626
Quarter Section: 3
CITY OF ANAHEIM
BUILDING DMSION
200 S. ANAHEIM BLVD.
(714) 765 - 5153
Site Address: 1320 S ORIOLE ST, ANAHEIM, CA 92804
Legal Description: N TR 3501 BLK LOT 25 r'
APN:13437301
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.
1 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 tabor 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 carder and policy are:
Carrier: STATE COMPENSATION INSURANCE FUND Policy No.: 9162522 Expiration Date: 12/9/2023
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
workers compensation laws of California, and agree that, if 1 should become subject to the workers compensation provisions of Section 3700 of the
Ld%or Code. I shall forthwith comoly with those omvisions_
Applicant
S A /'Z' -
Date , I
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:
Lenders Address:
S D CONTRACTOR'S DECLARATION:
affi under the penalty of Perjury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Drvisi n 3 of the Business and
Ions to, and my license Is In full force and effect.
v v
Irtor Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE (Sl
974125 10/31/2023 C10, B
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