424 S LAURELTREE DR (4)Permit Types
BLD ELE MEC PLM
X X X
Permit Number: BLD2022-04830
Issued: 11/15/2022
www.anaheim.net/building
(714)765.4626
Quarter Section: 219
CITY OF ANAHEIM
Site Address: 424 S LAURELTREE DR, ANAHEIM, CA 92808
Legal Description: N TR 12988 BLK LOT 89
APN:35422218
WORKER'S COMPENSATION DECLARATION:
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(7141 765 - 5153
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.
h C
1 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 worker's Compensation insurance carrier and policy are:
Carrier: SIRIUS AMERICA INSURANCE COMPANY Policy No.: WC9121900 Expiration Date: 2112/2023
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, it I should become subject to the worker's compensation provisions of Section 3700 of the
or Code, l shall forthwith comply with those provisions.
Signature of Applicant
r
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
Professlons e, and my license Is In full force and effect
Contractor Signature
NUMBER EXPIRATION DATE LICENSE TYPE (Sl
942422 01/31@024
Z-2 , :�' e2
Date