1262 N EVERGREEN ST (2)Permit Types _
BLD ELE MEC PLM
X I X
Permit Number: BLD201i.00516`
Issued: 02/22/2023
www.anaheim.neUbuilding
(714)765-4626
Quarter Section: 101
CITY OF ANAHEIM
BUILDING DMSION
200 S. ANAHEIM BLVD.
(714) 765-5153
Site Address: 1262 N EVERGREEN ST, ANAHEIM, CA 92805
Legal Description: N TR 2573 BLK LOT 11
APN: 07348203
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 pedury one of the following declarations:
I have and will maintain a certificate of consent to self4nsure 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 tabor Code, for the performance of the work for which
this permit is issued. My worker's Compensation insurance carrier and policy are:
Cartier. STATE COMPENSATION INSURANCE FUND Policy No.: 9291646 Expiration Date: 2IM024
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 worker's compensation provisions of Section 3700 of the
La Code, I sh rOhwith comply with those provisions.
2--Zz-23
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:
LICENSED CO TOWS DECLARATION:
I hereby sill under lh penally of Perjury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Profess s CO
a my license Is in full fo and effect.
2_ Z -2. E, 3
Contractor Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE ISI
1071038 11/30/2024 C10