1156 N FEE ANA STPermit Types
BLD ELE MEC PLM
X
Permit Number: BLD2023-02524
Issued: 05/23/2023
www.anaheim.net/building
(714)765-4626
Quarter Section: 160
Site Address: 1156 N FEE ANA ST, Anaheim, CA 92807
Legal Description: P BK 63 PG 37 PAR 2
APN: 34643110
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:
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
Secdon 3700 of the Labor Code, for the performance of the work for which this permit is Issued.
1 have and will maintain worker's 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:
Cartier: REDWOOD FIRE AND CASUALTY INSURANCE CO Policy No.: HOWC320544 Expiration Date: 6/1/2023
Name of Agent: Phone No.:
I ce�Ishs
rmance 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
laws ofCalifo and agree that, if I should become subject to the worker's compensation provisions of Section 3700 of the
with cothose Drovisions.
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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:
'S DECLARATION:
of Perjury that 1 am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
e is in full fbpAVd effect.
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Date
NUMBER
EXPIRATION DATE
LICENSE TYPE (S)
475568 06/30/2023 C39