1801 E KATELLA AVE (24)Permit Types
BLD ELE MEC PLM
X
Permit Number 13LD202341536
Issued: 04/03/2023
www.anaheim.net/building
(714)765.4626
Quarter Section: 107
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(7141765.5153
Site Address: 1801 E KATELLA AVE 1110, Anaheim, CA 92805
Legal Description: N TR 16618 BLK LOT 1 UN 1110 TRACT 16618, LOT 1 OF
APN:93028683
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 pedury 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
AIL 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
OW this permit is issued. My workers Compensation Insurance carrier and policy are:
Cartier. GENERAL CASUALTY COMPANY OF WISCONSIN Policy No.: 162000448 Expiration Date: 11123/2023
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
bor Code, I shall forthwith comply with those provislons.
D /'—) Y/3���
S' n lure 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):
Lender's 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.
L'4� #11. . fi 'Q —
Contractor 'rat
NUMBER EXPIRATION DATE LICENSE TYPE (Sl
443682 11/30/2024 B, C-6
G/ -? W
Date