2411 W LA PALMA AVE (44)Permit Types
BLD ALE MEC PLM
X I X I X X
Permit Number: BLD2023-00208
Issued: 04/18/2023
www.anaheim.net/building
(714)765-4626
Quarter Section: 24
CITY OF ANAHEIM
Site Address: 2411 W LA PALMA AVE, ANAHEIM, CA 92801
Legal Description: P BK 26 PG 49 PAR 1 PM 26-49 PAR 1 & 2
APN:07106127
BUILDING OMSION
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 ATTORNEYS 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 workers 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 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. ARCH INDEMNITY INSURANCE COMPANY Policy No.:14WC18925114 Expiration Date: 11112024
Name of Agent: Phone No.:
1 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 workers compensation provisions of Section 3700 of the
r Code, I shall forthwith comply with those provisions.
Signature o Applicant Date—
DECLARATION
ate
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
I hereby affirm under penalty of pedury 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 1 am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions C nd my license is in full force and effect. Ad
Contra or nature Date
NUMBER EXPIRATION DATE LICENSE TYPE (St
492944 09/30/2024