2112 S STATE COLLEGE BLVD (5)Permit Types
BLD ELE MEC PLM
X X
Permit Number. BLD2022-04506
Issued: 11/01/2022
wwmanaheim.nef/building
(714)765-0626
Quarter Section: 119
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 -5153
Site Address: 2112 S STATE COLLEGE BLVD, ANAHEIM, CA 92806
Legal Description: P BK 3 PG 12 PAR 2 P.M. 3-12 PAR. 2 AND TR 71 LOT
APN: 08327137
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.
1 hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certificate of consent to selfainsure 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. TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA Policy No.: UB9M69819322—,E_xpirraStion Date:1/1@023
Name of Agent: _ 60L.17M v AS5 CG - Phone No.: t to Z1-JyT 01 " t' 4 i0 0
I certify that in the performance of the work for which this perdt is issued, I shall not employ any person in any manner so as to become subject to the
workers compensation laws of California, and agree that, N 1 should become subject to the worker's compensation provisions of Section 3700 of the
Labor Code, l all to cors ' those p sions.
- -- __- 111_ -
Si lure f Applicant 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
Pialelsons Code, and my license Is in fidlOdGiand effect
ArAA,��17 XAAAA.,�l
ctor Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE ISI
745030 01/31/2022 S. C10, C45