150 W VERMONT AVEPermit Types .
BLD ELE MEC PLM
X
Permit Number: OLD2022-05672
Issued: 11/30/2022
www.anaheim.net/building
(714)765-0626
Quarter Section: 85
CITY OF ANAHEIM
Site Address: 150 W VERMONT AVE, ANAHEIM, CA 92805
Legal Description: P BK 38 PG 19 PAR 1
APN: 23417119
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(7141765-5153
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 self4nsure for workers 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.
WI have and will maintain worker's compensation insurance, as required by Section 3700 of the tabor Code, for the performance of the work for which
this permit is issued. My worker's Compensation insurance carrier and policy are:
Carrier. REDWOOD FIRE AND CASUALTY INSURANCE CO Policy No.: CBNC350599 Expiration Date:111/2023
Name of Agent:
Phone No.:
1 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
4 workers compensation laws of California, and agree that, if I should become subject to the workers compensation provisions of Section 3700 of the
Labor Pkde, I shall forthwith comply with those provisions.
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DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
I hereby affirm under penaltyof-perjury-that thereis-a-construction lending agency for the performance of the work for which this -permit Is -Issued --•— — -- -- . —
(Sec.3097.Civ.C):
Lenders Name:
Lenders Address:
LICENSED CONTRACTOR'S DECLARATION:
PA(ereby 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
essions Code, qnd my license Is In full force and effect.
NUMBER EXPIRATION DATE
701434 01/3112023
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C39, C46
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Date