134 S WESTERN AVE (4)Permit Types
BLD FELE MEC PLM
X
Permit Number: BLD2022-05367
Issued: 11/10/2022
www.anaheim.neUbuilding
(714)765-4626
Quarter Section: 9
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CITY OF ANAHEIM
BUILDING DMSION
200 S. ANAHEIM BLVD.
(7141765- 5153
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Legal Description: S TWP 4 RGE 11 SEC 14 SEC 14 T 4 R 11 W 337.52 FT
APN: 13528108
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 ATTORNEYS FEES.
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a ceRficate 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.
1 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. STARNET INSU ANCE COMPANY Policy No.: 1799007 Expiration Date: 7/1/2023
Name of Agent:
Phone No.:
V 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
is compensation laws of California, and agree that, If I should become subject to the workers compensation provisions of Section 3700 of the
Code, l shall forthwith comply with those provisions.
t t, t o''
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 CONTRACTOR'S DECLARATION:
I hereby affirm under the nal OfRldul`Y that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Dhdsion 3 of the Business end
Professions Code, and°my lice is in full force and effect.
Contractor SI atu
Date
NUMBER EXPIRATION DATE LICENSE TYPE (SI
1067161 07/31/2024 C39, C39, C39