1237 E HAMPSHIRE AVEPermit Types .
FXBLD ELE MEC PLM X X
Permit Number: BLD2022-05432
Issued: 11/15/2022
www.anaheim.neUbuilding
(714)765-0626
Quarter Section: 104
CITY OF ANAHEIM
Site Address: 1237 E HAMPSHIRE AVE, ANAHEIM, CA 92805
Legal Descrlptlon: N TR 1683 LOT 9
APN: 08230110
BUILDING DIVISION
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.
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certificate of consent to selfoinsure 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 time 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 worker's Compensation insurance carrier and policy are:
Cartier. STATE COMPENSATION INSURANCE FUND Policy No.: 9271102 Expiration Date: 2MA023
Name of Agent: Phone No.:
I certify that in the performance of the work for which this permit is issued, l shall not employ any person in any manner so as to become subject to the
rkera compensation laws of California, and agree that, if I should become subject to the worker's compensation provisions of Section 3700 of the
bor Code, I shall fbrthvAth comply with those provisions.
-9, 11111 l z�
Sig ture of Applicant Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
1 hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work for which this penult Is Issued
(Sec.3097.Civ.C):
Lender's 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
Professio s C Ade, amend my license is in full force and effect.
1f�
Contractor Signature
NUMBER EXPIRATION DATE LICENSE TYPE ISI
1043410 08/31/2022
1(Ir�1�-�
Date