2865 W SKYWOOD CIR (2)Permit Types
BLD ELE MEC PLM
X
Permit Number: BLD2023-02140
Issued: 05/02/2023
www.anaheim.net/building
(714)765-0626
Quarter Section: 13
CITY OF ANAHEIM
She Address: 2865 W SKYWOOD CIR, ANAHEIM, CA 92804
Legal Description: N TR 2400 BLK LOT 114
APN:12609430
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(7141765.5153
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 ($700.000), 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 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.
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 workers Compensation insurance carrier and policy are:
Carrier: STATE NATIONAL INSURANCE COMPANY INC Policy No.: AMX1440034003 Expiration Date: 55/1/2024
Name of Agent Phone No.:
I car* that in the performance of evor915r'WFiicMhi eimit is issued, l shall not employ any person in any manner so as to become subject to the
workers compensati lifo ' nd agree that, if I uld become subject to the workers compensation provisions of Section 3700 of the
Labor Cod all forth ose p cions.
LZ
Sian o ADDllca 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 I
I hereby affirm
NUMBER
pffalty of Poly" 1 am licensed der provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
MEE.5-/7-
/12
Date
EXPIRATION DATE LICENSE TYPE (S)
937280 09/30/2023 D24, D52, D64, D03, C-8