1210 S STATE COLLEGE BLVD (6)Permit Types
PLMMECELEBLD
X X
Permit Number: BLD2025-00395
Issued:
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 - 5153
CITY OF ANAHEIM
www.anaheim.net/building
(714)765-4626
Quarter Section: 116
APN: 25314124
Legal Description: P BK 117 PG 19 PAR 1 PM 117-19 PAR 1 POR OF PAR -
Site Address: 1210 S STATE COLLEGE BLVD ANAHEIM, CA 92806
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 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:
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 worker's compensation provisions of Section 3700 of the
Labor Code, I shall forthwith comply with those provisions.
DateSignature of Applicant
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.
Contractor Signature Date
EXPIRATION DATENUMBER LICENSE TYPE (S)
Carrier: Policy No.: Expiration Date:
Name of Agent: ___________________________________________________ Phone No.: __________________________
Docusign Envelope ID: CF3FD95D-0966-433A-AE55-CE73BE3E4D25
7/3/2025
Docusign Envelope ID: 5839757C-02DF-4328-808F-B4D619306D3B
David Fernandez
WVE 5080859 00 // 11.2.2025
7/3/2025
818.986.7283Paramount Exclusive Insurance Services, Inc