1757-1807 N RAYMOND AVEPermit Types
BLD ELE MEC PLM
X
Permit Number: BLD2022-04503
Issued: 09/21/2022
www.anaheim.net/building
(714)765-0626
Quarter Section: 80
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 - 5153
Site Address: 1757-1807 N RAYMOND AVE, ANAHEIM, CA 92801
Legal Description: S TWP 3 RGE 10 SEC 34 SEC 34 T 3 R 10 POR SE1/4
APN: 26902105
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 8706 OR THE LABOR CODE. INTEREST, AND ATTORNEYS FEES.
1 hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certificate of consent to selfansure for worker's compensation, issued by the Director of Industrial Relations as provided for by
Section 3700 of the tabor 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. INSURANCE COMPANY OF THE WEST Policy No.: WSD506452000 Expiration Date: 3/1/2023
Name of Agent: Phone No.:
I certify that it 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 worker's compensation provisions of Section 3700 of the
bor Cade, I shall forthwith comply with those provisions.
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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 perm is issued
(Sec.3097.Civ.C):
Lender's Name:
Lenders 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 C de, and y icense is in full force and effect.
Contra6or Signature
NUMBER EXPIRATION DATE LICENSE TYPE IS
959243 03/31/2023 C39, C39, C39, C39, C39
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Date