2239 W VANCOUVER DRPermit Types
BLD ELE MEC PLM
X
Permit Number: BLD2022-05744
Issued: 12/05/2022
www.anaheim.net(building
(714)7654626
Quarter Section: 34
CITY OF ANAHEIM
Site Address: 2239 W VANCOUVER DR, ANAHEIM, CA 92804
Legal Description: N TR 2701 BLK LOT 27
APN:12725311
BUILDING DMSION
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 ATTORNEYS FEES.
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certificate of consent to selfinsure for worker's compensation, issued by the Director of Industrial Relations as provided for by
Section 3700 of the labor Cade, for the performance of the work for whIc h this permit is issued.
5� 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
YYY this permit is issued. My worker's Compensation insurance carrier and policy are:
Cartier: STATE COMPENSATION INSURANCE FUND Policy No.: 9216807 Expiration Date: 81012023
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
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
13A
I A Mheseprovisions.
xv-
Signat 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):
Lenders 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 Code, iq0 hs*ft i II rce and effect.
Contractor 9%in-Wer' " / Date
NUMBER EXPIRATION DATE LICENSE TYPE ISl
1030562 08/31@023 C39