2400 E ORANGEWOOD AVE (5)Permit Types .
BLD ELE MEC PLM
X
Permit Number: BLD202244613
Issued: 04/19/2023
www.anaheim.net/building
(714)765-4626
Quarter Section: 129
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 -5153
Site Address: 2400 E ORANGEWOOD AVE, ANAHEIM, CA 92806
Legal Description: S TWP 4 RGE 10 SEC 25 SEC 25 T 4 R 10 POR W1/2
APN: 23201119
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:
1 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.
1 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:
Carrier: STATE COMPENSATION INSURANCE FUND Policy No.: 9298784 Expiration Date: 5/25/2023
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
workVs compensation laws of California, and agree that, if I should became subject to the workefs compensation provisions of Section 3700 of the
forthwith comply with those provisions.
Of
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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 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 a nd my I' rise Is In fait force and effect.
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Conyictor Signal re Date
NUMBER EXPIRATION DATE LICENSE TYPE ISl
988686 11/30/2024 B, A