1477 N JEFFERSON ST (7)Permit Types .
BLD I ELE I MEC PLM
X I X
Permit Number:13LD2023-01370
Issued: 05/23/2023
www.anaheim.net/building
(714)765-0626
Quarter Section: 148
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765-5153
Site Address: 1477 N JEFFERSON ST, ANAHEIM, CA 92807
Legal Description: A TR HAZARDS SUB BLK LOT 35 HAZARDS SUB LOT 35 N 2
APN: 34516102
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:
1 have and will maintain a certificate of consent to self4nsure for workers 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 workers Compensation insurance carrier and policy are:
Cartier. CYPRESS INSURANCE COMPANY Policy No.: DAWC425978 Expiration Date:1/1@024
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
Lrabgbr Code, I shall forthwith comply with those provisions.
S�n of pljcant 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 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 Division 3 of the Business and
Professions Code, a dam' y license IsJ1p full force and effect.
Cantrav " Signa dr a Date
NUMBER EXPIRATION DATE LICENSE TYPE IS
861151 07/31/2023