5818 E PASEO MAGELLAN (7)Permit Types
BLD ELE MEC I PLM
X X
Peanut Number: E;i 'v,.. 3-01208 n'
Issued: 03/14/2023
www.anaheim.net/building
(714)765-4626
Quarter Section: 185
CITY OF ANAHEIM
Site Address: 5818 E PASEO MAGELLANANAHEIM, CA 92807
Legal Description: N TR 7769 BLK LOT 92
APN: 36317114
BUILDING DIVISION
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.
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 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:
Carrier: CYPRESS INSURANCE COMPANY Policy No.: BAWC432476 Expiration Date: 1/112024
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
rker's compensation laws of California, and agree that, if I should become subject to the worker's compensation provisions of Section 3700 of the
Le or Code, I shall forthwith comply with those provisions. Z
Signatu bof Applicant Date 11
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 my license is in full force and effect.
Contractor Signature
NUMBER EXPIRATION DATE LICENSE TYPE IS)
592661 04/30/2022
Date