1820 N CYMBAL WAY (4)Permit Types
BLD ELE MEC PLM
X X
Permit Number: BLD2023-01123
Issued: 03/08/2023
wwmanaheim.net/building
(714)765-0626
Quarter Section: 171
Site Address: 1820 N CYMBAL WAY, ANAHEIM, CA 92807
Legal Description: N TR 6688 BLK LOT 19
APN:34320415
CITY OF ANAHEIM
BUILDING[ DIVISION
o u..
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 ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED
FOR IN SECTION 3706 OR THE LABOR CODE. INTEREST, AND ATTORNEY'S FEES.
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certificate of consent to self -Insure for workers compensation, Issued by the Director of Industrial Relations as provided for by
Section 3700 of the labor Code, for the performance of the work for which this permit is Issued.
L -L I have and will maintain workers compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which
this permit Is issued. My workers Compensation insurance carrier and policy are:
Carrier. STATE COMPENSATION INSURANCE FUND Policy No.: 9267444 Expiration Date: 1119f2024
Name of Agent - Phone No.:
I certify that in the performance of the work for which this permit is issued, i shall not employ any person In any manner so as to become subject to the
workers compensation laws of California, and agree that, if I should become subject to the workers compensation provisions of Section 3700 of the
Labor Code, I shall forthwith comply with those provisions.
3�$(Z3
Signatu f Applicant Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
I hereby affirm under penalty of perjury that there is a construction [ending agency for the performance of the work for which this permit Is Issued
(Sec.3097.Civ.C):
Lenders Name:
Lenders Address:
LICENSED CONTRACTOR'S DECLARATION:
1 hereby affirm under the penalty of Perjury that 1 am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is In full force and effect.
Contract gnature
NUMBER EXPIRATION DATE LICENSE TYPE (S)
1038451 04/30/2022
3I71i3
Date