247 S LARKWOOD ST (3)Permit Types
BLD I ELE MEC I PLM
X
Permit Number: BLD2023-00259
Issued: 01/19/2023
www.anaheim.net/building
(714)765-0626
Quarter Section: 219
CITY OF ANAHEIM
BUILDING DMSION
200 S. ANAHEIM BLVD.
(714) 765 -5153
Site Address: 247 S LARKWOOD ST, ANAHEIM, CA 92808
A
Legal Description: N TR 10984 BLK LOT 29 r,
APN: 35403110
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 self -insure for worker's compensation, Issued by the Director of Industrial Relations as provided for by
n 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: ACE AMERICAN INSURANCE COMPANY Policy No.: C61749030 Expiration Date: 101112023
Name of Agent: Phone No.:
I certify that in the performance of the work for which this permit is issued, l shall not employ any person in any manner so as to become subject to the
worker's core gpna laws of California, and agree that, if I should become subject to the worker's compensation provisions of Section 3700 of the
Labor C shall_forthwith MpywWthose provisions.
Signatunevf 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:
Lender's 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, a nae is in full force and effect. 2
1 /1 -� /,-,P,
Contractor Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE is)
933396 05/31/2022 C10