1926 W RANDOM DR (3)Permit Types
BLD ELEMEC PLM
X
Permit Number:13LD2023-00439
Issued: 01/27/2023
www.anaheim.net/building
(714)765-4626
Quarter Section: 41
Site Address: 1926 W RANDOM DR, Anaheim, CA 92804
Legal Description: N TR 2712 BLK LOT 19
APN:12821205
CITY OF ANAHEIM
BUILDING DMSION
�L'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 ATTORNEYS FEES.
I hereby affirm under penalty of pedury one of the following declarations:
HN
Hieu Nguyen
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 FARM FIRE AND CASUALTY COMPANY Policy No.: 92WQ8169 Expiration Date: 3/2312023
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 worker's compensation provisions of Section 3700 of the
Labor Code, l shall forthwith comply with those provisions.
1/27/2023
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 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 force and effect.
VOLT TECH ELECTRIC 1/27/2023
Contractor Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE (S)
1008549 10/31/2023 C70, B