2157 W LA PALMA AVE (4)Permit Types
BLD ELE MEC PLM
X
Permit Number: OLD2023-01149
Issued: 05/18/2023
www.anaheim.net/building
(714)765-4626
Quarter Section: 37
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(7141 765 - 5153
Site Address: 2157 W LA PALMA AVE, Anaheim, CA 92801
Legal Description: S TWP 4 RGE 10 SEC 5 T4S R1 OW SEC 5 POR SWIM
APN:07241550
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.
1 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 workers Compensation insurance carrier and policy are:
Carrier. CLEAR SPRING PROPERTY AND CASUALTY COMPANY Policy No.: CWC01319400 Expiration Date: 11/18/2023
Name of Agent: Phone No.:
Ice_jbd 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
worke s compensation laws of California, and agree that, N I should become subject to the workers compensation provisions of Section 3700 of the
ni7' =
those provisions.
Signatu 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:
I hereby affi the penalty of Perjury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
ons Cod , and my license Is In full force and effect.
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Contrac or Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE ISl
1098770 11/30/2024