2929 E WHITE STAR AVE (7)Permit Types. _
BLD ELE ME4m-
Permit
X Number: BLD2023-00131
Issued: 03/24/2023
www.anaheim.net/building
(714)765.4626
Quarter Section: 140
CITY OF ANAHEIM
Site Address: 2929 E WHITE STAR AVE, ANAHEIM, CA 92806
Legal Description: P BK 123 PG 46 PAR 4
APN:34408108
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 pedury one of the following declarations:
I have and will maintain a certificate of consent to selfansure 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. Policy No.: Expiration Date:
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 lawsiXTCalifornia, and agree that, If I should become subject to the worker's compensation provisions of Section 3700 of the
Labor Code, l shallfo th cam with those provisions.
Signature of Ap licant Date oor
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:
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
ssi s Code, and my [icons full force and effect.
31" X22
Contractor Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE (S)
1076923 06/30/2023 D24