4328 E ELKSTONE AVE (2)Permit Types
BLD I ELE I MEC PLM
X F X
Permit Number: OLD2022-04931
Issued: 10/24/2022
www.anaheim.net/building
(714)765-4626
Quarter Section: 162
CITY OF ANAHEIM
Site Address: 4328 E ELKSTONE AVE, ANAHEIM, CA 92807
Legal Description: N TR 5409 SLK LOT 8
APN: 35908311
BUILDING DMSION
200 S. ANAHEIM BLVD.
(711411765-5153
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 perjury one of the following declarations:
I have and will maintain a certificate of consent to self4nsure for workers compensation, Issued by the Director of Industrial Relations as provided for by
JF 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 patio ere:
Cartier. FALLS LAKE FIRE AND CASUALTY COMPANY Policy No.: FLA00086506 Expiration Date: 811512023
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 Calftmia, and agree that, if I should become subject to the workers compensation provisions of Section 3700 of the
Labor Code, I shall forthwith comply with those provisions.
John Fitzmaurice 1024/2022
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 CONTRACTOR'S DECLARATION:
1 hereby affmrn 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 effect.
J D F CONSTRUCTION INC
Contractor Signature
NUMBER EXPIRATION DATE LICENSE TYPE ISl
956749 01/312023 B. C20, C39, C10, ASB, D41, C17
Date
10242022