706 S ELDER STPermit Types
BLD ELE MEC PLM
X
Permit Number. OLD2023-01727
Issued: 04/13/2023
www.anaheim.net/building
(714)7654626
Quarter Section: 104
Site Address: 706 S ELDER ST, ANAHEIM, CA 92805
Legal Description: N TR 1959 BLK LOT 29
APN:08235507
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 affirm under penally 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 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:
Carrier. STATE COMPENSATION INSURANCE FUND Policy No.: 9287512 Expiration Date: 11/6@023
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
worker compensation laws of California, and agree that, If I should become subject to the workers compensation provisions of Section 3700 of the
e al forthwith comply With those provisions. G� 2
`Signa re of Applicant. Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
1 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 d my li a is in full force and effect. t 7
Co or Si ature Date
7
NUMBER EXPIRATION DATE LICENSE TYPE.(S)
418550 11/30/2022 C39