624 S ANDOVER DRPermit Types
BLD ELE MEC PLM
X
Permit Number: BLD202341999
Issued: 04/26/2023
www.anaheim.neUbuilding
(714)765-4626
Quarter Section: 175
Site Address: 624 S ANDOVER DR, ANAHEIM, CA 92807
Legal Description: N TR 9268 BLK LOT 24
APN:36143107
WORKER'S COMPENSATION DECLARATION:
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 - 5153
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 affirn under penalty of pedury one of the following declarations:
I have and will maintain a certificate of consent to selfansure 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 workers Compensation insurance carrier and policy are:
Cartier. OLD REPUBLIC INSURANCE COMPANY Policy No.: MWC314159 Expiration Date: 10/1/2023
Na a of Agent: Phone No.:
I ce 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
work es compensation laws of California, and agree that, if I should become subject to the workers compensation provisions of Section 3700 of the
Labor de, I shall forthwith comply with those provisions.
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:
Lender's Address:
LICE SED C TRACTOR'S DECLARATION:
1 hereb attirm u er the penalty of Perjury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Profe ns Code and my license Is in full force and effect.
Contractor Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE IS
990416 07/31/2023 B. C17