233 E CENTER STPermit Types
BLD
ELE
MEC
PLM
X
X
Permit Number: BLD2020.02868
Issued: 07/03/2024
www.anaheim.nettbu ilding
(714)7654626
Quarter Section: 83
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 -5153
Site Address: 233 E CENTER ST, ANAHEIM, CA 92805
Legal Description: P BK 217 PG 14 PAR 2
APN: 25507616 Mill
WORKER'S COMPENSATION DECLARATION:
WARNING: FAILURE TO SECURE WORKERSCOMPENSATION 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 workers compensation, issued by the Director of Industrial Relations as provided for by
i Section 3700 of the Labor Cade, for the performance of the work for which this permit is issued.
have and will maintain workers 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: INSURANCE COMPANY OF THE WEST Policy No.: VVTX504806804 Expiration Date: 5/1/2024
Name of
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 warkers compensation provisions of Section 3700 of the
Labor Code, I shall forthwith comply with those provisions.
Signature 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):
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 lie Is in full force and effect.
2 Z -
Contractor Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE ISI
1104224 05/31/2025 C70