929 E SOUTH STPermit Types
BLD ELE MEC PLM
X
Permit N1tltlir 3��°'p
Issued: 03/09/2023
www.anaheim.net/building
(714)765-4626
Quarter Section: 94
CITY OF ANAHEIM
BUILDING DIVISION
"200 S. ANAHEIM BLVD.
(714) 765 - 5153
Site Address: 929 E SOUTH ST, ANAHEIM, CA 92805
Legal Description: A TR VINEYARD LOTS BLK LOT H1 VINEYARD LOTS LOT H-
APN: 03713015
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
Section 3700 of the Labor Code, for the performance of the work for which this permit is issued.
I 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 worker's Compensation insurance carder and policy are:
Cartier: STATE COMPENSATION INSURANCE FUND Policy No.: 9303084 Expiration Date: 8/312023
Name of Agent
Phone No.:
1 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
rkers compensation laws of California, and agree that, if I should become subject to the worker's compensation provisions of Section 3700 of the
bor Crtmply with those provisions.
lure of Appl n 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 Cc , and my license is in full force and effect.
/a3
on or Ignature Date
NUMBER EXPIRATION DATE LICENSE TYPE (St
1077446 06/30/2023 C10