475 S PASEO BANDERA (4)Permit Types
BLD ELE MEC PLM
X
Permit Number: OLD2023-02038
Issued: 05/01/2023
www.anaheim.net/building
(714)765.4626
Quarter Section: 186
CITY OF ANAHEIM
Site Address: 475 S PASEO BANDERAANAHEIM, CA 92807
Legal Description: N TR 8672 BLK LOT 10
APN:36320131
BUILDING DMSION
200 S. ANAHEIM BLVD.
(714) 765.5153
WORKER'S COMPENSATION DECLARATION:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES
AND CML 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 seliansure 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.
EV
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 artier end 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, l shelf not employ any person In any manner so as to become subject to the
workers compensation laws of California, and agree that, It 1 should become subject to the workers compensation provisions of Section 3700 of the
Labor Code, I shall forthwith comply with those provisions.
Eric Ville 5/1/2023
Signature of Applicant
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 eNrm 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 Code, and my license is in full force and effect.
FERMONT ELECTRIC 5/1/2023
Contractor Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE (S)
1021072 11/30/2022 C10
� J 23