6508 E PASEO DIEGOPermit Types
BLD ELE MEC PLM
X X
Permit Number. BLD2023-00487
Issued: 03/28/2023
www.anaheim.net/building
(714)765.4626
Quarter Section: 286
Site Address: 6508 E PASEO DIEGOANAHEIM, CA 92807
Legal Description: N TR 8141 BLK LOT 54
APN:36501922
CITY OF ANAHEIM
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
Sefton 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 workers Compensation insurance carrier and policy are:
Cartier: NATIONAL CASUALTY COMPANY Policy No.: WCC334024A Expiration Date: 61112023
Name of Agent: Phone No.:
I certify that in the performance of the work for which this permit is issued, l 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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Signature of Appl nt Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
I hereby affirm under penalty of perjury that there is a construction lending agency for gra performance of the work for which this permit is Issued
(Sec.3097.Civ.C):
Lenders 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 (S)
1029644 08/31/2023 B, C10, C46, C39
3M.51 ff3
Date