601 S ALVY STPermit Types
BLD 1 ELE MEC PLM
X
Permit Number: BLD2024-03462
Issued: 07/08/2024
www.anaheim. neVbuilding
(714)7654626
Quarter Section: 55
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714)765.5153
Site Address: 601 S ALVY ST, Anaheim, CA 92802
Legal Description: A TR HELEN & LYNCH ADD BLK LOT 20 HELEN & LYNCH AD -
APN: 25007102 - r
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 ceni8cate of consent to self -insure for workers 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.
it 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
`3 this permit is issued. My worker's Compensation insurance carrier and policy are:
Carrier: STATE COMPENSATION INSURANCE FUND Policy No.: 1860441 Expiration Date: 1 /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 compensation laws of California, and agree that, if I should become subject to the workers compensation provisions of Section 3700 of the
Labor Code, I shall forthwith comply with those provisions.
Ll
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:
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.
P
Contractor Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE IS)
574763 08/31/2025 C39