1926 W RANDOM DR (4)Permit Types
BLD ELE I MEC PLM
X
Permit Number: BLD2023-00488
Issued: 02/08/2023
www.anaheim.neUbuilding
(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
200 S. ANAHEIM BLVD.
(714) 765 - 5153
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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
HN 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 workefs Compensation insurance carrier and policy are:
Canter. Policy No.: Expiration Date:
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, I shall forthwith comply with those provisions.
Hieu Nguyen 2/8/2023
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.
MASAH ELECTRIC
Contractor Signature
NUMBER
1079459
EXPIRATION DATE
08/31/2023
LICENSE TYPE IS
C10
Date
2/8/2023
6/23