713 S ECHO STPermit Types
BLD
ELE
MEC
FILM
X
X
X
I X
Permit Number: BL02024-01757
Issued: 07/05/2024
vvww.anaheim.net/building
(714)765-4626
Quarter Section: 48
Site Address: 713 S ECHO ST, Anaheim, CA 92804
Legal Description: N TR 2425 BLK LOT 166
APN: 12823110
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 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 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.
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 carder and policy are:
Cartier: STATE COMPENSATION INSURANCE FUND Policy No.: 9225128 Expiration Date: 1/30/2024
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 comp sation laws of Califomia, and agree that, if I should become subject to the worker's compensation provisions of Section 3700 of the
Labor Code, I hall forthwith comply with those provisions.
Signature OTAPPIAA1 Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
I hereby aftirn under penalty of perjury that there Is a construction lending agency for the performance of the work for which this permit is issued
(8ec.3097.Civ.C):
Lender's Name:
Lender's Address:
LICENSED CONTRACTORS DECLARATION:
I hereby affirm under the penal of Perjury that I am licensed udder provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions Code, and rpy lice se is In full force and effect.
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Date
NUMBER EXPIRATION DATE LICENSE TYPE IS)
1034806 01/31/2024