4636 E TANGLEWOOD AVE (6)Permit Types
BLDALE MEC PLM
X
Permit Number. BLD2023-02497
Issued: 05/22/2023
www.anaheim.net/building
(714)765.4626
Quarter Section: 165
CITY OF ANAHEIM
BUILDING DIVISION
100 S. ANAHEIM BLVD.
(714) 765 - 5153
Site Address: 4636 E TANGLEWOOD AVE, Anaheim, CA 92807
Legal Description: N TR 5988 BLK LOT 1 ;
APN:34308330
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:
I have and will maintain a certificate of consent to seff4nsure for worker's compensation, issued by the Director of Industrial Relations as provided for by
n c Sermon 3700 of the Labor Code, for the performance of the work for which this permit Is issued.
J\W 1 have and will maintain workers 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. OLD REPUBLIC INSURANCE COMPANY Policy No.: MWC314158 Expiration Date: 101112023
Name of Agent:. Phone No.:
— I I 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 (he
workers compensation laws of California, and agree that, If 1 should become subject to the workers compensation provisions of Section 3700 of the
Labor lode,Mhall forthwith comply with those provisions.
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 permit is Issued
(Sec.3097.Civ.C):
Lender's Name:
Lender's Address:
Code,
Signature
,CTOR'S DECLARATION:
penalty of Perjury that t am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
iy license is in full force and effect.
NUMBER EXPIRATION DATE
990416 07/31/2023
LICENSE TYPE (SI
B. C17
�- 22-'2
Date