1309 W IONIA PL (4)Permit Types
BLD ELE MEC PLM
X X
Permit Number: BLD2022-06057
issued: 12J21/2022
www.anaheim.net/building
(714)765-4626
Quarter Section: 51
Site Address: 1309 W IONIA PL, ANAHEIM, CA 92801
Legal Description: N TR 2270 BLK LOT 6
APN: 27104106
CITY OF ANAHEIM
BUILDING DMSION
200 S. ANAHEIM BLVD.
1714) 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 pedury one of the following declarations:
I have and will maintain a certificate of consent to self4nsure 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.
1 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 workers Compensation insurance carder and policy are:
Cartier: TRAVELFRS EROP UA COMPANY OF AMERJG6Policy No.: U09KO711OA2226G Expiration Dale: 4/2912023
12023
Name of Agent: rl\ QAxAA1 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
workers compensation laws of California, and agree that, if 1 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 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:
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 Dhdsion 3 of the Business and
Professions Code, and my license is in full force and effect.
5LV� AV49-
Contractor Signature
NUMBER EXPIRATION DATE LICENSE TYPE (S)
704414 03/31/2023 B. C36, C20, C10, C-2
►/a. 15 1pz
Date
(r.