1520 E PINEWOOD AVE (3)Permit Types
BLD ELE MEC PLM
X I X
Permit Number: BLD2022-05298
Issued: 02/22/2023
www.anaheim.neUbuilding
(714)765-0626
Quarter Section: 101
CITY OF ANAHEIM
Site Address: 1520 E PINEWOOD AVE, Anaheim, CA 92805
Legal Description: N TR 2570 BLK LOT 23
APN: 07341605
BUILDING,
PIVISION
reE 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 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.
1 hereby affirm under penalty of perjury one of the following declarations:
141
1 have and will maintain a certificate of consent to self4nsure 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.
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 carder and policy are:
Cartier: OLDU S CO P lioy No.: MWC31431822
Name of Agent:
Expiration Date:01 /1/2023
Phone No.:
1 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 workers compensation provisions of Section 3700 of the
*MW07
ovisions.
Signature of Applicant
Q -c
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 CONTRACTOR'S DECLARATION:
I 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 Code, and myI nse is in full force and effect.
OtL&
Contractor Signature
NUMBER EXPIRATION DATE LICENSE TYPE ISI
1080382 08/31/2023 C46, CIO, C-2, 8
Date