842 S HARDING AVEPermit Types
BLD ELE MEC PLM
X
Permit Number. BLD2023-00132
Issued: 01/12/2023
www.anaheim.neUbuilding
(714)765-4626
Quarter Section: 10
Site Address: 842 S HARDING AVE, ANAHEIM, CA 92804
Legal Description: N TR 3822 BLK LOT 11
APN:07946246
CITY OF ANAHEIM
BUILDING DMSION
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 ATTORNEY'S FEES.
1 hereby affirm under penalty of perjury one of the following declarations:
1 have and will maintain a certificate of consent to self -insure 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 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. OLD REPUBLIC INSURANCE COMPANY Policy No.: MWC314156 Expiration Date: 101112023
Name of Agent:
Phone No.:
Ice 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
work is compensation laws of California, and agree that, if I should become subject to the workers compensation provisions of Section 3700 of the
Labo ��Opde, I shall forthwith comply with those provisions.
V.
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:
n 1
LICENSED CONITRACTOR'S DECLARATION:
1 hereby affirm under the penally of Perjury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
ProfessionCode, a�, my license is In full force and effect.
kr U /,I)-23
Contractor Signature
NUMBER
EXPIRATION DATE
LICENSE TYPE IS)
990416 07/31/2023 B. C17
Date