205 N PAGEANT ST (4)Permit Types
BLD ELE MEC PLM
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Permit Number: BLD2023-02203
Issued: 05/08/2023
www.anaheim.net/buiiding
(714)765-4626
Quarter Section: 162
Site Address: 205 N PAGEANT ST, ANAHEIM, CA 92807
Legal Description: N TR 4476 BLK LOT 48
APN:35915218
WORKER'S COMPENSATION DECLARATION:
CITY OF ANAHEIM
BUILDING DMSION
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
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
this permit is issued. My workers Compensation insurance carrier and policy are:
Cartier. Policy No.: Expiration Date:
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
workers compensation laws of California, and agree that, if I should become subject to the workers compensation provisions of Section 3700 of the
Labor Code, I shall forthwith comply with those provisions.
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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:
Lenders Address:
LICENSED CONTRACTOR'S DECLARATION:
I hereby affirm under the penalty of Perjury that 1 am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions Cade hd filly license is in to force and effect.
Date
NUMBER EXPIRATION DATE LICENSE TYPE 1S1