1335 S FANN STPermit Types
BLD ELE MEC PLM
X
Permit Number. BLD2023-00871
Issued: 02/22/2023
www.anaheim.net/building
(714)765-4626
Quarter Section: 49
Site Address: 1335 S FANN ST, ANAHEIM, CA 92804
Legal Description: N TR 1902 BLK LOT 5
APN: 12838505
CITY OF ANAHEIM
BUILDING DIVISION
200 !P'E1r�AHE11Gl 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 selfansure 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� I 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:
Carters ACE AMERICAN INSURANCE COMPANY Policy No.: WCUC68916446 Expiration Date: 311/2023
Name of Agent:
Phone No.:
I ce ' at 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
rkees compensation laws of California, and agree that, if I should become subject to the worker's compensation provisions of Section 3700 of the
bor de, I sh forth 'th co ply with those provisions.
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:
Lenders Address:
LICENSED CO TUTOR'S DECLARATION:
1 hereby affl nder the penal ury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Profession Code, a mylice Le is in II force and effect.
Contractor Signature Date
NUMBER EXPIRATION DATE
602331 09/30/2024
LICENSE TYPE (S)
C10, B. D12, C-2, C39, C-6, C17, C36, D34, D41, D24