834 N HARBORPermit Types
BLD ELE MEC PLM
X
Permit Number: BLD2024-02817
Issued: 07/23/2024
w .anaheim.net/bui(ding
(714)765.4626
Quarter Section: 71
Site Address: 834 N HARBOR BLVD, ANAHEIM, CA 92805
Legal Description: N TR 601 BLK LOT 35
APN: 03424106
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 - 5153
WORKER'S COMPENSATION DECLARATION:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECTAN 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 ATTORNEYS 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.
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: STATE COMPENSATION INSURANCE FUND Policy No.: 9288501 Expiration Date: 11/255/.,2024
Name of Agent: i���C� Phone No.: 7J �.
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 a ifo , and agree that, if I should become subject to the worker's compensation provisions of Section 3700 of the
Labor
those
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 CON1
I hereby affirm under
my license is
NUMBER EXPIRATION DATE
931407 04/30/2025
licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
4Ls13�
-7/2� �Z .
Date