2390 E ORANGEWOOD AVE 550Permit Types
BLD ELE MEC PLM CITY OF ANAHEIM
X X X
BUILDING DIVISION
Permit Number: BLD2021-04833 200 S. ANAHEIM BLVD.
Issued: 01/19/2022 (714) 765 - 5153
www.anaheim.net/building
(714)765-4626
Quarter Section: 119
Site Address: 2390 E ORANGEWOOD AVE 500, ANAHEIM, CA 92806
Legal Description: P BK 173 PG 39 PAR 1
APN: 23201151
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 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.
1 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:
Carrier: FALLS LAKE FIRE AND CASUALTY COMPANY Policy No.: FLA0126340 Expiration Date: 9/21/2022
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
Labor Code, I shall forthwith comply with those provisions.
ZA. —
Signature of Applicant
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 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, d m icense is in full force and effect.
Contractor Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE (S)
747567 03/31/2022