1640 S STADIUM VIEW AVEPermit Types
BLD ELE MEC PLM
X
Permit Number: BLD2023-00745
Issued: 03/28/2023
www.anaheim.neUbuilding
(714)765-1626
Quarter Section: 117
CITY OF ANAHEIM
BUILDING DMSION
200 S. ANAHEIM BLVD.
17141 765 - 5153
Site Address: 1640 S STADIUM VIEW AVE, ANAHEIM, CA 92806
Legal Description: P SK 186 PG 16 PAR 9 PM 186-16 PAR 9 THRU 11
APN:25362101
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.
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 workers Compensation insurance carrier and policy are:
Cartier. TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA Policy No.: UB4P3293162314G Expiration Date:11112024
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, if I should become subject to the worker's compensation provisions of Section 3700 of the
Labor Code, I shall forthwith comply with those provisions.
Applicant
03/2 g/wz 3
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):
Lenders Name:
Lenders 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 Code, and my license Is In full force and effect.
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NUMBER EXPIRATION DATE LICENSE TYPE ISI
(SI
1062365 01/31/2024 D24
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