618 S SHIELDS DRPermit Types .
BLD ELE MEC PLM
X
Permit Number. BLD2023-01636
Issued: 04/07/2023
wwmanaheim.net/building
(714)765-4626
Quarter Section: 21
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(7141765-5153
Site Address: 618 S SHIELDS DR, ANAHEIM, CA 92804
Legal Description: N TR 5108 BLK LOT 34
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APN: 12616304
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 selfinsure 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.
t�.II1 y 1 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 COMPENSATION INSURANCE FUND Policy No.: 9077368 Expiration Date: 3/1/2024
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
worker's compensation laws of California, and agree that, it I should become subject to the worker's compensation provisions of Section 3700 of the
\ r Code, I shall forthwith comply with those provisions.
SlignaMWIFf Applicant.
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
Date 1
1 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):
Lenders Name:
Lender's Address:
LICENSED CONTRACTOR'S DECLARATION:
I hereby affirm under the penalty of Perjury that I am licensed under provislons of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions Code, end my license is in full force and effect.
Contractor Signature
NUMBER EXPIRATION DATE LICENSE TYPE (S)
847279 09/30/2024 B, C39
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Date