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119 S KINGSLEY ST (2)Permit Types BLD ELE MEC PLM X X X X Permit Number.13LD202245046 Issued: 10/24/2022 www.gnaheim.net/building (714)765-4626 Quarter Section: 133 Site Address: 119 S KINGSLEY ST, ANAHEIM, CA 92806 Legal Description: N TR 4412 BLK LOT 18 APN: 26805101 WORKER'S COMPENSATION DECLARATION: CITY OF ANAHEIM BUILDING DIVISION 200 S. ANAHEIM BLVD. (714) 765 - 5153 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 ($700,000), 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 self -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 Labor Code, for the performance of the work for which this permit is issued. My workers Compensation insurance carrier and policy are: Cartier. Policy No.: Expiration Date: 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. 11ANtl. - - - - - - - - • Ot:-� • • _ 2✓1 r 2 ©2� - cSign re of Applicant Date l 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: 1 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 etfecL J,?.A . /-A 4 Contra or Signa ure NUMBER EXPIRATION DATE LICENSE TYPE (S) U C"� ZI 4 2- ,,Date Date