307 S GAIN STPermit Types
BLD ELE MEC PLM
X
Permit Number: BLD2022-04979
Issued: 12/08/2022
www.anaheim.net/building
(714)765-0626
Quarter Section: 27
Site Address: 307 S GAIN ST, ANAHEIM, CA 92804
Legal Description: N TR 2440 BLK LOT 2
APN:12715105
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
1714) 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 self4nsure for worker's compensation, issued by the Director of Industrial Relations as provided for by
j Section 3700 of the Labor Code, for the performance of the work for which this permit is issued.
1 have and will maintain workers compensation Insurance, as required by Section 3700 of the tabor Code, for the performance of the work for which
this permit is issued. My worker's Compensation insurance carrier and policy are:
Carrier. SECURITY NATIONAL INSURANCE COMPANY Policy No.: SWC1403641 Expiration Date: 81312023
Name of Age�1t: 1 0 AE Phone No.: �- �Z
Signature
I certify 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
workef cImpensation laws of California, and agree that, if I should become subject to the worker's compensation provisions of Section 3700 of the
La rCo*, I shall forthwith comply with those provisions.
jUXJ 2 -2 -
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:
LICENSED CONTRAR'S DECLARATION:
I hereby afnn under th alty of Perjury that i am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions Code, a my cone is in full force and effect.
Contractor
NUMBER EXPIRATION DATE
1018274 09/30/2024
LICENSE TYPE (S)
C-6, B
Z �Z
Date