3001-3003 E VIA SIENA (3)Permit Types
BLD ELE MEC PLM
X
Permit Number. BLD2022-04656
Issued: 09/30/2022
wwwAnaheim.net/building
(714)765-4626
Quarter Section: 141
Site Address: 3001-3003 E VIA SIENAANAHEIM, CA 92806
Legal Description: N TR 7802 BLK LOT 89
APN: 26819214
WORKER'S COMPENSATION DECLARATION:
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(7141 765 - 5153
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 ATTORNEYS 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.
t� I have and will maintain worke'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: MIDWEST EMPLOYERS CASUALTY COMPANY Policy No.: BNUWC0155960 Expiration Date: III WOZ3
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
worker's compensation laws of California, and agree that, if 1 should become subject to the worker's compensation provisions of Section 3700 of the
Labor Code, I shall forthwith comply with those provisions.
SI at plioant 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:
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.
ContigWr Ig ature
NUMBER EXPIRATION DATE LICENSE TYPE (S)
1048449 01/31/2023 B, B. C39, C39
Date