1919 S STATE COLLEGE BLVD (21)Permit Types
BLD ELE MEC PLM
X X X X
Permit Number: BLD2022-05411
Issued: 05/22/2023
www.anaheim.net/building
(714)765-1626
Quarter Section: 108
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(7141 765 -5153
Site Address: 1919 S STATE COLLEGE BLVD, ANAHEIM, CA 92805
Legal Description:
APN: 23212120
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 ATTORNEYS FEES.
I hereby affirm under penalty of pedury 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.
have and will maintain worker's compensation insurance, as required by Section 3700 of the tabor Code, for the performance of the work for which
this permit is issued. My worker's Compensation insurance carrier and policy are:
Cartier: OAK RIVER INSURANCE COMPANY Policy No.: CAWC353093 Expiration Date: 6120023
Name of Agent: Phone No.:
1 certify that in the performance of Ore or 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 5P9 domi ,and agree that, O I should become subject to the workefs compensation provisions of Section 3700 of the
I shall forth comply th those provisions.
r
Signature of
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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 Code, and my license is in fuJ Jd6?e and effect.
Contractor Sig,
NUMBER
332960
l
EXPIRATION DATE
08/31/2023
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A. B, C16
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Date