2563 E LARK ELLEN LN (2)Permit Types
BLD GLE MEC PLM
X
Permit Number: BLD2023-00412
Issued: 01/26/2023
wwwAnaheim.net/'building
(714)765-0626
Quarter Section: 126
CITY OF ANAHEIM
Site Address: 2563 E LARK ELLEN LN, ANAHEIM, CA 92806
Legal Description: N TR 9425 BILK LOT 83
APN:25346114
BUILDING DIVISION
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 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.
r%�C, I 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: STATE COMPENSATION INSURANCE FUND Policy No.: 9303073 Expiretion Date: 6/3/2023
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 Calif mis, and that, if I should become subject to the worker's compensation provisions of Section 3700 of the
Labor Code I with tho provisions.
Ol - ;2 23 �
Signature o 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 DECLARATIONj
I hereby affirm under the penalty of Perjury that I a y censed un provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my licer is in full fo nd effect.
Contractor
NUMBER
977779
EXPIRATION DATE
10/31/2024
LICENSE TYPE (St
C10
d/ —:2 17
Date