4125 E LA PALMA AVE (2)Permit Types
BLD ELE MEC PLM
X
Permit Number: BLD2023-01105
Issued: 04/07/2023
www.anaheim.net/building
(714)765.4626
Quarter Section: 154
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BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 - 5153
Site Address: 4125 E LA PALMA AVE, ANAHEIM, CA 92807
Legal Description: P BK 206 PG 6 PAR 3 YORBA LINDA TRACT BLK 36 LOT L
APN:34606106
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.
1 hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certficate 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.
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
Z L this permit is issued. My worker's Compensation insurance carrier and policy are:
Carrier: FEDERAL INSURANCE COMPANY Policy No.: 64310335 Expiration Date: 7 013112 02 3
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, If I should become subject to the workers compensation provisions of Section 3700 of the
Labor Code, I shall forthwith comply with those provisions.
-7 2023
Signature of Applican7 ,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:
Lenders 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
Professions Code, and my license Is in full force and effect.
Contractor Signature
17
NUMBER EXPIRATION DATE LICENSE TYPE (SI
960119 02/28/2023
4 /7 / ?023
Date -