3142 W TYLER WAYPermit Types
BLD ELE MEC PLM
X X X X
Permb Number. BLD2022-04843
Issued: 05/17/2023
www.anaheim.nef/buiiding
(714)765.4626
Quarter Section: 8
Site Address: 3142 W TYLER WAY B, Anaheim, CA 92801
Legal Description: N TR 1820 BLK LOT 71
APN:13522110
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 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 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:
Cartier: STATE FARM FIRE AND CASUALTY COMPANY Policy No.: 92KFZ6106 Expiration Date: 12/12/2023
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
worke's. compensation laws of California, and agree that, If I should become subject to the worker's compensation provisions of Section 3700 of the
Code, l sholl forthwith comply with Mose provisions.
5- 11- -Z3
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:
1 hereby affirm und empenalty of Perjury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions Code an my license is in hill force and effect.
Contractor Siglitilb Date
NUMBER EXPIRATION DATE LICENSE TYPE (SI
1066777 09/30/2022