1477 S MANCHESTER AVE (19)Permit Types
BLD ELE MEC PLM
X X X X
Permit Number: BLD2023-00670
Issued: 05/17/2023
Wwanaheim.net/building
(714)765-4626
Quarter Section: 86
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(7141 765 - 5153
Site Address: 1477 S MANCHESTER AVE, ANAHEIM, CA 92802
Legal Description: A TR JOSEPH FISCUS SUB BLK LOT 7 JOSEPH FISCUS SUB
APN: 08217041
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 selfansure 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
(J this permit is issued. My worker's Compensation insurance carrier and policy are:
Cartier: ARCH INDEMNITY INSURANCE COMPANY Policy No.:14WC18925114 Expiration Date: 111/2024
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 California, and agree that, If I should become subject to the worker's compensation provisions of Section 3700 of the
�sbor Code, I shall forthwith comply with those provisions.
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Sighfituti of Applicant Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
I hereby effirm 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 provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions and my license is In full force and effect.
Con for Signature
NUMBER EXPIRATION DATE LICENSE TYPE /S)
492944 09/30!2024
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