601 S FANN PL (3)Permit Types
BLD ELE MEC PLM
X
Permit Number. BLD2022-04673
Issued: 10/03/2022
www.anaheim.net/building
(714)765-4626
Quarter Section: 48
Site Address: 601 S FANN PL, ANAHEIM, CA 92804
Legal Description: N TR 3672 BLK LOT 1
APN: 12824319
CITY OF ANAHEIM
BUILDING DIVISION
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:
1 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 worker's Compensation insurance carrier and policy are:
OLD REPUBLIC INSURANCE COMPANY Policy No.: MWC314158 Expiration Date: 1011/2023
of Agent Phone No.:
Icey that in the performance of the work for which this permit Is issued, l shall not employ any person in any manner so as to become subject to the
workrs compensation laws of California, and agree that, H I should become subject to the workers compensation provisions of Section 3700 of Ore
Labe %ode, I shall forthwith comply with those provisions.
Signature of
Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
I hereby atftrtn 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:
Lenders Address:
SED CONiCTOR'S DECLARATION:
affirm undo the penalty of Perjury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
ons Code, anV my ficense is In full force and effect.
Date
NUMBER EXPIRATION DATE LICENSE TYPE IS
990416 07/31/2023 B, C17