9291 W HOUSTON AVEPermit Types
BLD ELE MEC PLM
X X
Permit Number: BLD2023-01739
Issued: 04/27/2023
www.anaheim.net/building
(714)765-4626
Quarter Section: 23
CITY OF ANAHEIM
Site Address: 9291 W HOUSTON AVE, ANAHEIM, CA 92801
Legal Description: N TR 4187 BLK LOT 15
APN:07148211
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 ATTORNEYS FEES.
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certificate of consent to salt -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 workers compensation Insurance, as required by Section 3700 of the tabor Code, for the performance of the work for which
this permit is issued. My workers Compensation Insurance terrier and policy are:
Cartier:
Name of Agent.
Policy No.: WC614287001 Expiration Date: 1011/2023
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 worker's compensation provisions of Section 3700 of the
Labor Code, I shall forthwf comply with those provisions.
%Z— - N / -2-77 J(Z-3
W1 Applicant Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
I hereby af0nn 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:
LIC ED CONTRACTOR'S DECLARATION:
I h by a rm 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
ProfNesqscode, and my license is In full to
nd effect.
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ractor IgnatureDate
NUMBER EXPIRATION DATE LICENSE TYPE (S)
750184 06/30/2024 C10, C46, C39, 8