1719 E WILLOW ST (3)Permit Types
BLD ELE MEC PLM
X I X
Permit Number: BLD2022-06029
Issued: 01/18/2023
wormanaheim.net/building
(714)765-4626
Quarter Section: 103
Site Address: 1719 E WILLOW ST, ANAHEIM, CA 92805
Legal Description: N TR 1565 BLK LOT 191
APN: 03721232
WORKER'S COMPENSATION DECLARATION:
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 - 5153
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 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 COMPENSATION INSURANCE FUND Policy No.: 9306867 Expiration Dale: 10/8/2023
Name of Agent:
Phone No.:
I ceRiy that ' ape rmance 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 mpensati n laws of California, and agree that, if I should become subject to the worker's compensation provisions of Section 3700 of the
Le Code, I sha orthwith comply with those provisions.
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Signat re of Appli t 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:
LICENSED CONTOR'S D CLARATION:
I hereby affirm undprolhe penalty of P rjury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions Ca and my license i In full force and effect.
NUMBER EXPIRATION DATE
1038376 04/3012022
LICENSE TYPE (S)
B, C39, C10, A
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