1160 N FEE ANA STPermit Types
BLD ELE MEC PLM
X
Permit Number: BLD2023-02525
Issued: 05/23/2023
www.anaheim.net/buiiding
(714)765-4626
Quarter Section: 160
Site Address: 1160 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 ATTORNEYS FEES.
I hereb affirm under penalty of perjury one of the following declarations:
1 have and will maintain a certificate of consent to self -Insure for workers 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 workers 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 certify tha performance of the work for wh permit is Issued, l shall not employ any person in any manner so as to become subject to the
,Ire ars compen tion laws of Califomte, ag at, if I should become subject to the workers compensation provisions of Section 3700 of the
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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:
Lenders Address:
LICENSED CON 'S DECLARATION:
I hereby of i oder enahy Perjury that I am licensed under rovisions of chapter 9 (commencing With Section 7000) of Division 3 of the Business and
Professions Co an y li a Is In full nd effect.
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c Signat Date
NUMBER EXPIRATION DATE LICENSE TYPE is)
475568 06/30/2023 C39