1175 S HIDDEN CANYON RD (4)Permit Types
BLD ELE ME4m-
Permit
X Number: OLD2023-01736
Issued: 04/13/2023
www.anaheim.nef/building
(714)765-0626
Quarter Section: 288
CITY OF ANAHEIM
BUILDING OMSION
200 S. ANAHEIM BLVD.
(714) 765 - 5153
Site Address: 1175 S HIDDEN CANYON RD, ANAHEIM, CA 92807
Legal Description: N TR 10998 BLK LOT 1
APN:36541101
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 affmn under penalty of perjury one of the following declarations:
I 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
DSection 3700 of the Labor Code, for the performance of the work for which this permit is issued. ?
' 1 have and will maintain worker's compensation insurance, as required by Section 3700 of the Labor Code, for the perfomrandeobthe work for which
this permit is Issued. My workers Compensation Insurance carrier and policy are: j
Cartier: EMPLOYERS PREFERRED INSURANCE COMPANY Policy No.: ODZN439172 Expiration Date: 12/812023
Name of Agent:
Phone 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
worker's compensation laws of California, and agree that, If I should become subject to the workers compensation provisions of Section 3700 of the
Labor Code, I shall forthwith comply with those provisions.
Signature of Applicant
tLI3,L;3
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):
Lenders Name:
Lenders Address:
LICENSED CONTRACTOR'S DECLARATION:
I hereby affirm under the penalty of Perjury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is In full force and effect.
O�GJ:61 1A_
Contractor Signature
NUMBER EXPIRATION DATE LICENSE TYPE is)
1035546 02/29/2024 C39, 8
Date