705 S DORCHESTER ST (2)Permit Types
BLD ELE MEg-m—
Permit
X Number. BLD2023-02207
Issued: 05/08/2023
www.anaheim.nef/building
(714)765-4626
Quarter Section: 104
CITY OF ANAHEIM
Site Address: 705 S DORCHESTER ST, Anaheim, CA 92805
Legal Description: N TR 1697 BLK LOT 17
APN:08235516
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.
I hereby affirm under penalty of pedury one of the following declarations:
I have and will maintain a certificate of consent to selfdnsure for worker's compensation, issued by the Director of Industrial Relations as provided for by
/y, ,/� Section 3700 of the Labor Code, for the performance of the work for which this permit is issued.
1 E:1_� 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
V this permit is issued. My worker's Compensation Insurance carrier and policy are:
Cartier: STATE COMPENSATION INSURANCE FUND Policy No.: 9303901 Expiration Date: 8/18/2023
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
work" mpensetion laws of California, and agree that, It I should become subject to the workers compensation provisions of Section 3700 of the
I.WortCodo,1 shall forthwith comply with those provisions.
o5lg 2n23
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 unAOV49nafty of Perjury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions de, ar license Is In full force and effect.
"V'
2
�-510�.a0
Contractor ture Date
NUMBER EXPIRATION DATE LICENSE TYPE (S)
1079987 08/31/2023 C39