245 E FLORENCE AVEPermit Types
BLD ELE MEC PLM
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Permit Number: BLD2023-01908
Issued: 04/21/2023
www.anaheim.net/building
(714)765.4626
Quarter Section: 95
CITY OF ANAHEIM
Site Address: 245 E FLORENCE AVE, ANAHEIM, CA 92805
Legal Description: N TR 1379 BLK LOT 12
APN:23414311
BUILDING DMSION
200 S. ANAHEIM BLVD.
(714) 765 - 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 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.
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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
ithis permit is issued. My workers Compensation insurance carrier and policy are:
Carrier. STATE COMPENSATION INSURANCE FUND Policy No.:81 96132 Expiration Date: 211/2024
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
work es compensation laws of California, and agree that, If I should become subject to the workers compensation provisions of Section 3700 of the
LaCode, I shall forthwith comply with those provisions.
of Applicant
l v !
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.Ctv.C):
Lender's Name:
Lenders Address:
LICENSED CONTRACTOR'S DECLARATION:
1 hereby affirm under a 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 license is In full force and effect.
( 21 Z
--CIE-7Signature -Date `
NUMBER EXPIRATION DATE ) 1 jIcE) LICENSE jy PE (SIPE (Sl
911019 02129/2024 039,1349,1341