1126 N JASMINE STPermit Types
BLD ELE MEC PLM
X
Permit Number: BLD2023-02378
Issued: 05/15/2023
www.anaheim.net/building
(714)765-0626
Quarter Section: 37
Site Address: 1126 N JASMINE ST, ANAHEIM, CA 92801
Legal Description: N TR 2093 BLK LOT 25
APN: 07240509
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(7141 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 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.
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:
Carrier. SIRIUS AMERICA INSURANCE COMPANY Policy No.: WC9419301 Expiration Date: 3/23/2024
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
workers 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.
5 45—c;13
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):
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.
I vu.,
T.A.,
I
Contractor Signature
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NUMBER EXPIRATION DATE LICENSE TYPE (S)
1094725 07/31/2024 C39
Date