1243 N DRESDEN PLPermit Types
BLD ELE MEC PLM
X
kbit Nudnber. BLD2023-01191
Issued: 03/13/2023
www.anaheim.net/building
(714)765-0626
Quarter Section: 51
CITY OF ANAHEIM
Site Address: 1243 N DRESDEN PL 1-7, ANAHEIM, CA 92801
Legal Description: N TR 3396 BLK LOT 13
APN:07338427
BUILDING DIVISION
4 20U S�A��iE1M BLVD.
(714) 765 -5153
WORKEWS,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 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 worker's Compensation insurance carrier and policy are:
Cartier. FALLS LAKE FIRE AND CASUALTY COMPANY Policy No.: FLA020269 Expiration Date: 1/15/2024
Name of Agent:
Phone No.:
Ice ' at 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
rk is corn nation laws of California, and agree that, if I should become subject to the worker's compensation provisions of Section 3700 of the
Ls11"Code, I shall forthwith comply with those provisions.
a
Sffnature 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:
LICENSED CONTRACTOR'S D LARATION:
I hereby affirm under tj a penalty of P rjury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
my license I& full force and effect.
NUMBER EXPIRATION DATE
1054542 06/30/2023
LICENSE TYPE (S)
C17, C17, C17
"7 1'7 2
Date