2810 E RANDY AVEPermit Types
BLD ELE MEC PLM
X
Permit Number: BLD2022-04592
Issued: 09/27/2022
www.anaheim.net/building
(714)765-4626
Quarter Section: 135
Site Address: 2810 E RANDY AVE, ANAHEIM, CA 92806
Legal Description: N TR 3854 BLK LOT 11
APN:25333405
CITY OF ANAHEIM
BUILDING DIVISION
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 ATTORNEY'S FEES.
1 hereby affirm under penalty of pedury one of the following declarations:
I have end will maintain a certificate of consent to selfansure for workers 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 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 carrier and poficy are:
Cartier.
Policy No.: 9043501 Expiration Date:1/1/2023
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
` 1—Mworker pensation laws of California, and agree that, if I should become subject to the workers compensation provisions of Section 3700 of the
Cod , I shall forthwith comply with those provisions.
7A
Signature of App icant 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 DMslon 3 of the Business and
Profess)s Code, and my Ilcense Is in foil force and effect.
Contractor SignatumoprDate
NUMBER EXPIRATION DATE LICENSE TYPE (S)
694940 08/31/2023 C39