2063 W CORONET AVE (5)Permit Types
BLD ELE MEC PLM
X
Permit Number: BLD2023-00849
Issued: 02/22/2023
www.anaheim.net/building
(714)765-4626
Quarter Section: 37
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 - 5153
Site Address: 2063 W CORONET AVE, ANAHEIM, CA 92801
Legal Description: N TR 2197 BLK LOT 6 y.
APN:07230106
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 selfinsure 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:
Carrier. Policy No.: Expiration Date:
Name of Agent: Phone No.:
t 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
V� / worker co
Par
saUon laws of California, and agree that, if 1 should become subject to the worker's compensation provisions of Section 3700 of the
Lab Code I shall forthwith comply with those provisions.
,-fl�niv'\. 2 - 2 0 a
Signature o Applicar 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'ECRATION:
I hereby affirm under the penalty o Perjury t I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions Cade, and mYJlrens Is in full force and effect.
NUMBER EXPIRATION DATE
1045848 10/31/2024
LICENSE TYPE (S)
C10
Date