809 W NORTH STPermit Types . _
BLD ELE MEC PLM
X
Permit Number: BLD2023-01824
Issued: 04/18/2023
www.anaheim.net/building
(714)765-4626
Quarter Section: 61
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 - 5153
Site Address: 809 W NORTH ST, ANAHEIM, CA 92805
Legal Description: A TR ANAHEIM EXT BLK LOT 38 ANAHEIM EXT LOT 38 POR
APN:25512238
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 ($700,000), 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: Policy No.: Expiration Date:
Name of Agent:
Phone No.:
I certify thatUw# thate erfomIance 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
e mpe tion laws of California, and agree that, it I should become subject to the worker's compensation provisions of Section 3700 of the
labor e, I, hall forthwitil comply with those provisions.
' L
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:
WWCONTRACrrrTOS DECLARATION:
affirm under th hlene,I Perjury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
hQs Cade, ang1my cense la in fujVbrWand effect.
2-3
Date
NUMBER EXPIRATION DATE LICENSE TYPE ISl
918107 06/30/2024 a