721 S DORCHESTER STPermit Types
FX—BLD
ELE ME
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Permit Number. OLD2022-05475
Issued: 12101/2022
www.anaheim.net/building
(714)765.4626
Quarter Section: 104
CITY OF ANAHEIM
BUILDING OMSION
200 S. ANAHEIM BLVD.
(714) 765-5153
Site Address: 721 S DORCHESTER ST, ANAHEIM, CA 92805
Legal Description: N TR 1697 BLK LOT 20 ?
APN:08235513
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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 ATTORNEYS 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
SL Section 3700 of the Labor Code, for the performance of the work for which this permit is issued.
1 have and will maintain workers 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: STARR INDEMNITY &amo: LIABILITY COMPANY Policy No.: 1000005080 Expiration Date: 7/26/2023
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
workers compensation laws of California, and agree that, if I should become subject to the workers compensation provisions of Section 3700 of the
Labor Code, l shall forthwith comply with those provisions.
Sotcius LLC 12/1/2022
Signature of Applicant Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
hereby-atArm•under-penaltyof•pedury that there Is a construction4ending agency-foMheimWonaancevf-the•workdor 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 effecL
SOLCIUS LLC
Contractor Signature
NUMBER EXPIRATION DATE LICENSE TYPE IS)
976336 09/30/2024 C10, C46
Date
12/1/2022