3132 W GRACIOSA LN (2)Permit Types
BLD ELE MEC PLM
X X
Permit Number: BLD2022-05670
Issued: 12/20/2022
www.anaheim.nef/building
(714)765-4626
Quarter Section: 9
CITY OF ANAHEIM
Site Address: 3132 W GRACIOSA LN, ANAHEIM, CA 92804
Legal Description: N TR 2611 BILK LOT 173
APN:13529605
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(711411765-51153
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.
1 hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certificate of consent to seltinsure 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.
t✓— 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:
Cartier. STATE COMPENSATION INSURANCE FUND Policy No.: 9227796 Expiration Dale: 3/14/2023
Name of Agent: Plume No.:
I 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
workersmponsation laws of California, and agree that, f I should become subject to the workers compensation provisions of Section 3700 of the
Labor Co ee, I shat/l forthwith comply with those provisions.
ignature of "plicant
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.Crv.C):
Lender's Name:
Lenders Address:
LICENSED CONTRA57MPf DECLARATION:
I hereby affirm under penalty f Perjury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions Cod nd my li se is in full force and effect.
l7i�p Z �•
Contlifictor Sign re to
NUMBER EXPIRATION DATE LICENSE TYPE IS
1023006 01/31/2023