407 S PRIMROSE STPermit Types
BLD ELE MEC PLM
X I I d
Permit Number. BLD2023-01217
Issued: 03/14/2023
www.anaheim.net/building
(714)7654626
Quarter Section: 40
CITY OF ANAHEIM
BUILDING DIVISION
IRA AIAHEIM BLVD.
(714) 765 - 5153
Site Address: 407 S PRIMROSE ST, ANAHEIM, CA 92804
Legal Description: N TR 2369 BLK LOT 121 TR 2369 LOT 121 POR OF LOT A
APN: 12815420
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 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. ACE AMERICAN INSURANCE COMPANY Policy No.: WLRCS0668150 Expiration Date: 3/1/2024
Name of Agent: Phone No.:
I �t 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
rkers compensa ' laws of Califomia, and agree that, if I should become subject to the worker's compensation provisions of Section 3700 of the
Labq Code, I sII forth Ith mpty with those provisions.
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 nalty of Perjury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions Cod , a my license is in and effect.
4/11-6
Contractor Signature Date
NUMBER EXPIRATION DATE
602331 09/30/2024
LICENSE TYPE ISI
C10, B. D12, C-2, C39, C-6, C17, C36, D34, D41, D24
4us�" -lift Ind