139 W SIRIUS AVE (4)Permit Types
BLD ELE MEC PLM
X X
Permit Number: BLD2023-01685
Issued: 04/11/2023
www.anaheim.net/building
(714)76511626
Quarter Section: 89
Site Address: 139 W SIRIUS AVE B, ANAHEIM, CA 92802
Legal Description: N TR 3178 BLK LOT 8
APN:23308425
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
1714) 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.
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certificate of consent to selfainsure 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:
Policy No.: 9320737 Expiration Date: 7/13/2023
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
0 workers compen of California, and agree that, if I should become subject to the worker's compensation provisions of Section 3700 of the
be Code, I ail to th comply 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 the penglof ,jury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Prof@ssions Code, and myJ cense is 14 full force and effect.
(/_ //_ z�
Date
NUMBER EXPIRATION
1092059 05/31/2024