7550 E MARTELLA LNPermit Types
BLD ELE MEC PLM
X
Permit Number: BLD2023-02453
Issued: 05/18/2023
www.anaheim.net/building
(714)765-4626
Quarter Section: 202
Site Address: 7550 E MARTELLA LN, ANAHEIM, CA 92808
Legal Description: P BK 213 PG 21 PAR 4
APN:35622165
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 self -insure for worker's compensation, issued by the Director of Industrial Relations as provided for by
i� Section 3700 of the Labor Code, for the performance of the work for which this permit is Issued.
pr 1 have and will maintain workees 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. STATE COMPENSATION INSURANCE FUND Policy No.: 9258598 Expiration Date: 8/6/2023
Name of Agent:
Phone No.:
I certify that to 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
Oz.,.,ishall forthwith comply with those provisions.
Sig lure of Ap Ica 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).
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 Code, and my license Is in full force and effect.
o for Sig atur
NUMBER EXPIRATION DATE LICENSE TYPE ISI
1059050 08/31/2024 C39
K lb -p3
Date