526 S SANTIAGO WAY (2)Permit Types
BLD ELE MEC FILM
X
Permit Number: BLD2025-00598
Issued: 02/05/2025
www.anaheim.net/building
(714)765-4626
Quarter Section: 180
Site Address: 526 S SANTIAGO WAY ANAHEIM, CA 92807
Legal Description: N TR 7566 BLK LOT 60
APN: 36308305
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 ATTORNEY'S FEES.
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
lr^/ 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 carrier and policy are:
Carrier: STATE COMPENSATION INSURANCE F ND Policy No.: 9337159 Expiration Date: 4/1412025
Name of Agent:
Phone No.:
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 worker's compensation provisions of Section 3700 of the
Lab de, I shall forthwith comply with those provisions.
2-5--25
natur licant 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 mV license is in full force and effect.
2- 15
C tractor Signature Date
NUMBER EXPIRATION DATE LICENSETYPE is
976577 09/30/2022 C39