2300 E KATELLA AVE (13)Permit Types _
BLD ELE MEC PLM
X X X
Permit Number: BLD2022-04913
Issued: 12/14/2022
www.anaheim.net/building
(714)765-4626
Quarter Section: 117
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 - 5153
Site Address: 2300 E KATELLA AVE, ANAHEIM, CA 92806
Legal Description: A TR TRAVIS TR BLK LOT 6 TRAVIS TR LOT 6 POR OF LO
APN: 25353204
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 worker's compensation insurance, as required by Section 3700 of the tabor Code, for the performance of the work for which
this permit is issued. My worker's Compensation insurance tamer and policy are:
Cartier. INSURANCE COMPANY OF THE WEST Policy No.: WSD5038058 Expiration Date: 11/1512022
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, O I should become subject to the worker's compensation provisions of Section 3700 of the
bo ode, I shall forthwith comply with those provisions.
Signatu of Ap licant 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
P esslons Cod , and my license is in full force and effect.
ontractor Signature
NUMBER EXPIRATION DATE LICENSE TYPE ISI
'925760 12/31/2022 C-6, B, C15
22
ate