433 S PASEO REAL (2)Permit Types
BLD ELE MEC PLM
X
Permit Number: BLD2022-04.807
Issued: 10/10/2022
www.anaheim.net/bUilding
(714)765-0626
Quarter Section: 198
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 - 5153
Site Address: 443 S PASEO REALANAHEIM, CA 92807
Legal Description: N TR 8220 BLK LOT 56
APN:35601126 h
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 self -insure for worker's compensation, issued by the Director of Industrial Relations as provided for by
Section 8700 of the Labor Code, for the performance of the work for which this permit is issued.
1 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.:
Ice ' In a 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
vfiAees cFmpensafi laws California, and agree that, if I should become subject to the workers compensation provisions of Section 3700 of the
bar Co , I shall rthwith co ply wIth those provisions.
Signature of Applicant 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:
LICENSED RACTOWS DECLARATION:
I hereby nn 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
Prole Ions Cc e, and my licen s in force and effect.
Cant-ftor'Sifignature Date
NUMBER EXPIRATION DATE LICENSE TYPE IS!