1811 W GLEN AVEPermit Types
BLD ELE MEC PLM
X
Permit Number: BLD2023-01923
Issued: 04/24/2023
www.anaheim.net/building
(714)765-0626
Quarter Section: 44
CITY OF ANAHEIM
Site Address: 1811 W GLEN AVE A -D, ANAHEIM, CA 92801
Legal Description: N TR 3812 BLK LOT 50
APN:07256215
WORKER'S COMPENSATION DECLARATION:
BUILDING DIVISION
200 S. ANAHEIM BLVD.
1714) 765 - 5153
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 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. STATE COMPENSATION INSURANCE FUND Policy No.: 9200284 Expiration Date: 12N512023
Name of Agent: Phone No.:
1 certify that 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
workers compensation laws of California, and agree that, if I should become subject to the workers compensation provisions of Section 3700 of the
e7'
e, I sh tomtlmwith comply with those provisions.
V ZIA3
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:
Lender's Address:
LICENSED CONTRACTOR'S DECLARATION:
1 hereby effirm under the penal f Perjury I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions Code, m se Is In fur and effect.
y LYS 23
Contractor Signature Date
f
NUMBER EXPIRATION DATE LICENSE TYPE (S)
1022071 12/31/2024 C39, C39, C39, C39, C39