130 W LINCOLN AVE (12)Permit Types
BLD ELE MEC PLM
X X X
Permit Number: BLD2022-05365
Issued: 03/14/2022
www.anaheim.net/building
(714)765-0626
Quarter Section: 83
Site Address: 130 W LINCOLN AVE, ANAHEIM, CA 92805
Legal Description: P BK.148 PG 27'PAR 1
APN:25516105
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BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 - 5153
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 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 worker's 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. A 1 U INSURANCE COMPANY Policy No.: WCO25071441 Expiration Date: 6119023
Name of Agent: Phone No.:
I cey(!V 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
rk Ars
laws of California, and agree that, if I should become subject to the workers compensation provisions of Section 3700 of the
r de, I shall forthwith comply with those provisions.
D 2e ZZ
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:
LICENSED CONTRACTOR'S DECLARATION:
I hereby affirm u e the penalty of Perjury that 1 am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions Cafe/and my license is in hull force and effect
f /A 1212-Z
Date
NUMBER EXPIRATION DATE LICENSE TYPE IS
1031105 09/30/2023