1837 N HOLBROOK STPermit Types
BLD ELE MEC PLM
X X X X
Permit Number: BLD2023-00504
Issued: 02/21/2023
www.anaheim.neUbuilding
(714)765-0626
Quarter Section: 171
CITY OF ANAHEIM
Site Address: 1837 N HOLBROOK ST, ANAHEIM, CA 92807
Legal Description: N TR 5990 BLK LOT 41
APN:34309215
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 selfansum 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: Policy No.: Expiration Date:
Name of Agent:
Phone No.:
=1that in 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 co
pe sation laws California, and agree that, if I should become subject to the workers compensation provisions of Section 3700 of the
Labor , I all fo mply with those provisions.
2 Z f [2--Z,
Signatun: I Date
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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' E LARATI
I hereby affirm under the pen of Perj ry that licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions Code, and li nse Is i II , nd effect.
2A
ContractorSignet Date
NUMBER \EX, IRATION DAV LICENSE TYPE ISl
1083676 11/30/2023 B