135 S TOPO ST (4)Permit Types ._
BLD ELE MEC PLM
X
Permit Number. BLD2022-05531
Issued: 11/18/2022
www.anaheim.net/building
(714)765-0626
Quarter Section: 27
Site Address: 135 S TOPO ST, ANAHEIM, CA 92804
Legal Description: N TR 1940 BLK LOT 128
APN:12703313
CITY OF ANAHEIM
BUILDING) DIVISION
200 S. ANAHEIM BLVD.
(7141 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 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
✓ f� this permit is issued. My workers Compensation insurance carder and policy are:
Cartier: STARNET INSURANCE COMPANY Policy No.: SNUWC0156509 Expiration Date: 4/0/1023
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
workers compensation laws of California, and agree that, If I should become subject to the workers compensation provisions of Section 3700 of the
La nde, Lsh orlhwith comply with those provisions.
Signatu a of Applicant
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
/ VX12
Date
1 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.
ontrac S
NUMBER EXPIRATION DATE LICENSE TYPE ISI
1023627 02/28/2023 B, C10
/l 11 T zz
Date c