1428 S KNOTT AVE (2)Permit Types
BLD ELE ME4m-
Permit
X Number: BLD2022-04535
Issued: 09/23/2022
wwmanaheim.net/building
(714)765-4626
Quarter Section: 7
C�ifA•1f_1►T,1.I4IJ,I
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 - 5153
Site Address: 1428 S KNOTT AVE 200-207, ANAHEIM, CA 92804
Legal Description: S TWP 4 RGE 11 SEC 23 SEC 23 T 4 R 11 POR OF SEC
APN:07960102
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 selfansure 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:
Cartier. STATE COMPENSATION INSURANCE FUND Policy No.: 9200284 Expiration Date: 12/15/2022
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
worker's compensation laws of California, and agree that, if 1 should become subject to the worker's compensation provisions of Section 3700 of the
r
e,1 s II forthwith comply with those provisions.
Signature of Applicant
i�L 3 Z Z
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 Pe ry that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions Code nd fee 7�z
force and effect.
L3
ZL
Contractor Signature
NUMBER EXPIRATION DATE LICENSE TYPE (S)
1022071 12/31/2022 C39, C39, C39, C39, C39, C39
Date