1653 W LINCOLN AVEPermit Types
BLD ELE MEC PLM
X X
Permit Number: BLD2023-00523
Issued: 02/01/2023
www.anaheim.net/building
(714)765.4626
Quarter Section: 53
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 - 5153
`Site Address: 16531/2 W LINCOLN AVE, ANAHEIM, CA 92801
Legal Description: N TR 19017 BLK LOT 1 UN HOLD POR OF LOT 1 OF TRACT
APN: 07211056
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
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: OLD REPUBLIC INSURANCE COMPANY Policy No.: N WC31414822 Expiration Date: 9/1/2023
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
worker's compensation laws of California, and agree that, if I should become subject to the worker's compensation provisions of Section 3700 of the
Labor Code I shallfo th comply with those provisions.
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Signature of Applicant Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
1 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):
Lenders Name:
Lenders Address:
LICENSED CONTRACTOR'S DECLARATION:
1 ereby affirm un er the penal Perjury at I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Profs o Code, nd my 11 nse rce and effect.
2-11123
Contractor Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE (S)
728102 04/30/2024