4506 E LA PALMA AVEPermit Types
BLD ELE MEC PLM
X
Permit Number: BLD2023-00651
Issued: 02/08/2023
www.anaheim.net/building
(714)765-4626
Quarter Section: 166
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 - 5153
Site Address: 4506 E LA PALMA AVE, ANAHEIM, CA 92807
Legal Description: A TR F YORBA ALLOT 3RD CLASS LAND BLK F YORBA ALLO
APN:34619203
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 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:
Cartier. HARTFORD INSURANCE COMPANY OF THE MIDWEST Policy No.: 57WECZR4471 Expiration Data: 8 22MO23
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 1 should become subject to the worker's compensation provisions of Section 3700 of the
Labor Code, I shall forthwith comply with those provisions.
c
91 A
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:
Lender's 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 70001 of Division 3 of the Ri.aineaa ..A
Professions Code, and my license Is In full force and effect.
Contractor Signature
NUMBER EXPIRATION DATE LICENSE TYPE (S)
1012249 03131/2024 B. C17
a. -'2 -a3
Date