834 N MAGNOLIA AVE (7)Permit Types
BLD ELE MEC PLM
X
Permit Number. OLD202342500
Issued: 05/22/2023
wwrmanaheim.net/building
(714)765-4626
Quarter Section: 25
Site Address: 834 N MAGNOLIA AVE, ANAHEIM, CA 92801
Legal Description: N TR 1948 BLK LOT 13
APN:07127309
WORKER'S COMPENSATION DECLARATION:
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 -5153
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 selfinsure 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 wofkers 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. FALLS LAKE FIRE AND CASUALTY COMPANY Policy No.: ELA00086506 Expiration Date: 8/15/2023
Name of Agent: 61AVti Phone No.:
I cartify 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 worker's compensation provisions of Section 3700 of the
La bo e, I shall forthwith comply with those provisions.
Sae Z
Signatu Applicant 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 hereby affirm under the penalty of Perjury that I am licensed under provlslons of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions Code, andmy nse is in full force and effect.
I
C ntractor Vlature
NUMBER EXPIRATION DATE LICENSE TYPE iSl
956749 01/31/2025 B. C20, C39, C10, ASB, D41, C17
22 Z�
Date