5460 E LA PALMA AVE (16)Permit Types
BLD ELE MEC PLM
X
Permit Number: OLD2023-01517
Issued: 04/21/2023
www.anaheim.net/building
(714)765-4626
Quarter Section: 178
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 -5153
Site Address: 5460 E LA PALMA AVE, ANAHEIM, CA 92807
Legal Description: N TR 925 BLK LOT 3 TRACT NO 925 LOT 3 POR OF LOT A Y
APN:34645101
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 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.
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
this permit is Issued. My workers Compensation Insurance carrier and policy are:
Carder. AMERICAN CASUALTY COMPANY OF READING PA Policy No.: 7034613040 Expiration Date: 10/27/2023
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
workers corn nation laws of California, and agree that, if I should become subject to the workers compensation provisions of Section 3700 of the
r�Lebor Cod1 illiall forthwith comply with those provisions.
Tla-3
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 DECLARATION:
I hereb Niro under the pens of Perjury that I am licensed under provision of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
P =ions de, and my 09finsels in full force and effect.
LI a 3
Date
NUMBER EXPIRATION DATE LICENSE TYPE (S)
640058 11/3012021 B, C36, C20. C10