1729 N OAK KNOLL DR (4)Permit Types
CITY OF ANAHEIMBLDPLMELEMEC
X X
BUILDING DIVISION
200 S.ANAHEIM BLVD.
(714)765*5153
Permit Number:BLD2021*05203
Issued:01/26/2022
www.anaheim.net/building
(714)765-4626
Quarter Section:177
Site Address:1729 N OAK KNOLL DR,ANAHEIM,CA 92807
Legal Description:N TR 8828 BLK LOT 9
APN:34327209
WORKER'S COMPENSATION DECLARATION:
WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIESANDCIVILFINESUPTOONEHUNDREDTHOUSANDDOLLARS($100,000),IN ADDITION TO THE COST OF COMPENSATION.DAMAGES AS PROVIDEDFORINSECTION3706ORTHELABORCODE.INTEREST.AND ATTORNEY'S FEES.
I hereby affirm under penalty of perjury one of the following declarations;
I have and will matnlain a certificate of consent to self-insure for worker's compensation,issued by the Director of Industrial Relations as provided for bySection3700oftheLaborCode,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 whichthispermitisissued.My worker's Compensation insurance carrier and policy
Carrier:OHIO SECURITY INSURANCE COMPANY Policy No.:XWSS9104195 Expiration Date:10/1/2022
Name of Agent:
are:
Phone No.;
I certify that in the performance of (he work for which this permit is issued,I shall not employ any person in any manner so as to become subject to theworker's compensation laws of California,and agree that,if I should become subject to the worker's compensation provisions of Section 3700 of theLaborCode,I shall forthwith comply with those provisions.
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(Sec.3097.Civ.C):
Lender's Name:
Is issued
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 andProfessionCode,and my license is in full force and effect.
/.
Cofiffector Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE fSI
875966 04/30/2022 DOS,C29.B,C-8