2466 W TRANSIT AVE (2)Permit Types
BLD I ELE I MEC I PLM
X X
Permit Number: BLD2022-06064
Issued: 11/15/2022
www.ansheim.net/building
(714)765-4626
Quarter Section: 27
Site Address: 2466 W TRANSIT AVE, ANAHEIM, CA 92804
Legal Description: N TR 1940 BLK LOT 115
APN: 12704201
WORKER'S COMPENSATION DECLARATION:
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(7141766-6163
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 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.
(l 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. STATE COMPENSATION INSURANCE FUND Policy No.: 9302127 Expiration Date: 7/17/2023
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 became subject to the
worker's compensation laws of California, and agree that, t 1 should become subject to the worker's compensation provisions of Section 3700 of the
Labor Code, I shall forthwith comply with those provisions.
COA 11/16/2022
Signature of Applicant Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
I hereby etfam under penalty of perjury that there Is a construction lending agency for the performance of the work for which this pernit 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 full force and effect
COA op:raA %iQ/ii -
Contractor Signature
NUMBER EXPIRATION DATE LICENSE TYPE IS)
1053344 05/3112023 C10
11/16/2022
Date'