415 S KROEGER STPermit Types
BLD ELE MEC PLM
X
Permit Number: BLD2023416*'" `ire D':..EA• �`• ^
Issued: 03/06/2023
www.anaheim.net/building
(714)765-4626
Quarter Section: 83
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(7141765 - 6153
Site Address: 415 S KROEGER ST A -D, ANAHEIM, CA 92805
Legal Description: A TR LAIRD SUB BLK B LOT 41 LAIRD SUB LOT 41 BLK B
APN: 03711313
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 af0rm under penalty of perjury one of the following dedarations:
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 workers Compensation insurance carrier and policy are:
Cartier: STATE COMPENSATION INSURANCE FUND Policy No.: 9081726 Expiration Date: 11112024
Name of Age
t: Phare No.:
I oertihr in the performan 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
work s __a as
la eli=a, and agree that, if I should become subject to the workers compensatioions;afSction 3700 of the
or e I shall Rh mply with those provisions.
pro '
2
Signature ' pli nt 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:
LICENSEDTRACTOR'S D TION:
1 hereby af8 un r the penalty of t I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division f the Business and
ProfessJO d my license II fo nd effect.
2�
//1,
Contra i(fature Data
NUMBER EXPIRATION DATE LICENSE TYPE IS)
739156 08/31/2023 C39, C39, C39, C39, C39