400 S SUNKIST ST (15)Permit Types . .
BLD ELE MEC PLM
X
Permit Number: BLD202341815
Issued: 04/18/2023
www.anaheim.net/building
(714)7654626
Quarter Section: 123
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 - 5153
Site Address: 400 S SUNKIST ST 22-25, ANAHEIM, CA 92806
Legal Description: S TWP 4 RGE 10 SEC 12 SEC 12 T 4 R 10 POR SEI/4
APN:25323103
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 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. REDWOOD FIRE AC O Policy No.: CEWC456858 !ration ate: 411j2024
Name of Agent: Phone No.:
00000
00
I certify that in th ortn ce of t work f Ich this permit is issued, l shall not employ any person In any manner so as to become subject to the
workef�o pensetio aws ali(omi , and agree that, if I should become subject to the worker's compensation provisions of Section 3700 of the
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
I hereby affirm under penalty of pedury that there is a construction lending agency for the performance of the work for which this permit is issued
(Sec.3097.Civ.C):
Lenders Name:
Lenders Address:
LICENSED CONTRA 'S DE
I hereby aNirmu r the pe of&p
Profession ode. andffiv IicensaTs In
NUMBER
EXPIRATION DATE
licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business end
li915'0"
I
Dat 1
LICENSE TYPE (Sl
263519 11/30/2023 C39, C39, C39, C39, B. B. B. B