7460 E STONE CREEK LNPermit Types
BLD ELE MEC PLM
X X X
Permit Number: BLD2023-00853
Issued: 05/15/2023
www.anaheim.net/building
(714)765-0626
Quarter Section: 203
CITY OF ANAHEIM
Site Address: 7460 E STONE CREEK LN, ANAHEIM, CA 92808
Legal Description: N TR 8560 BLK LOT 55
APN:35635503
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 - 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 ($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 selfoinsure 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 end 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:
Carrier: Policy No.: Expiration Date:
Name of Agent: Phone No.:
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 compen of California, and agree that, If I should become subject to the worker's compensation provisions of Section 3700 of the
Labor Co ftarth th mply with those sions.
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Signa ure of 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):
Lenders Name:
Lenders Address:
LICENSED
I hereby affim
NUMBER
752602
DECLARATION:
Perjury that I am licensed under provisions of chapter 9 (commencing With Section 7000) of Division 3 of the Business and
my license 14 In full force
EXPIRATION DATE LICENSE TYPE (S)
05/3112025
3/1523
Date