1268 S NIGHT STAR WAY (2)Permit Types
BLD ELE MEC PLM
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Permit Number: BLD2023-00680p7
Issued: 02/09/2023
www.anaheim.net/building
(714)76511626
Quarter Section: 227
CITY OF ANAHEIM
Site Address: 1268 S NIGHT STAR WAY, ANAHEIM, CA 92808
Legal Description: N TR 13987 BLK LOT 18
APN:35454226
WORKER'S COMPENSATION DECLARATION:
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(7141 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 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 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 workers Compensation insurance carrier and policy are:
Carrier: STATE COMPENSATION INSURANCE FUND Policy No.: 9235198 Expiration Date: 7/20/2023
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
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
ao V611h th those provisions.
Sign re o 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):
Lenders Name:
Lender's Address:
LICENSED CONTRACTOR'S DECLARATION:
1 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 earksmy4tt�"'r`'ift ItrHe and effect.
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Contractor ` ature Date
NUMBER EXPIRATION DATE LICENSE TYPE Is
1042237 07/31/2024 C39