630 S KNOTT AVE 37-40 (2)Permit Types
BLD ELE MEC PLM
X
Permit Number: BLD2024.03755
Issued: 07/23/2024
www.anaheim. net/bu it d i ng
(714)7654626
Quarter Section: 6
CITY OF ANAHEIM
Site Address: 630 S KNOTT AVE 3740, Anaheim, CA 92804
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714)765. 5153
Legal Description: N TR 5107 BILK LOT 1 UN 37 TR 5107 LOT 1 UNIT 37 A-
APN:93620037 111MM&.
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 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 worker's compensation, issued by the Director of Industrial Relations as provided for by
Section 3700 of the Labor Cade, for the performance of the work for which this permit is issued.
tM1v�YNr— 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 tamer and policy are:
Cartier: NATIONAL CASUALTY COMPANY Policy No.: WCC336230A Expiration Date: 1 1/ 12025
Name of Agent:
Phone
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, g I should become subject to the workers compensation provisions of Section 3700 of the
Labor Code, I shall fortil am y with those provisions.
Z�
Si a re YApplica0 Date ��3/
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 license is in full force and effect.
Co recto Sign f e
NUMBER EXPIRATION DATE LICENSE TYPE fSl
531906 06/30/2024 C39, C39, C39, C39
Date