1278 N WILLAMETTE DR (4)Permit Types
BLD ELE MEC PLM
X X
Permit Number. BLD2022-05394
Issued: 12/02/2022
CITY OF ANAHEIM
www.anahelm.net/building
(714)765.4626
Quarter Section: 194
Site Address: 1278 N WILLAMETTE DR, ANAHEIM, CA 92807
Legal Description: N TR 7422 BLK LOT 2.0
APN: 35107103
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 CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (5100,000), 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 self -insure 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.
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 worker's Compensation insurance carrier and policy are:
Cartier. AMERI aANCE COMPAN Policy No: WC614287601 Expiration Date
: 10/112023
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 -
workers compensation laws of California, and agree than, N I should become subject to the workers compensation provisions of Section 3700 of the
Labor Code, l shall f th comply with those provisions. -•
Signature of Applicant -
Date 91
i- ---
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY.
'hereby-afliarwnder-penalty.of perjury -that there•i� e*rork-for4Wch this penult Is Issue"
(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
Professlons Code, and my license is In full force and affect. - -
Contractor Signature —�---�
- _ Date
NUMBER EXPIRATION DATE LICENSE TYPE is—)
750184 06/30/2024 C10, C46, C39. B