526 S SANTIAGO WAY (1)Permit Types
BLD ELE MEC PLM CITY OF ANAHEIM
X X
BUILDING DIVISION
Permit Number: BLD2025-00618 200 S. ANAHEIM BLVD.
Issued: 02/06/2025 (714) 765 - 5153
www.anaheim.net/building
(714)765-4626
Quarter Section: 180
Site Address: 526 S SANTIAGO WAY ANAHEIM, CA 92807
Legal Description: N TR 7566 BLK LOT 60
APN: 36308305
1
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:
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.
JG
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: UNITED WISCONSIN INSURANCE COMPANY Policy No.: WC04200118 Expiration Date: 6/1/2025
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 worker's compensation provisions of Section 3700 of the
Labor Code, I shall forthwith comply with those provisions.
Jesse Garay 2/19/2025
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:
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, and my license is in full force and effect.
Contractor Signature
NUMBER
359060
EXPIRATION DATE
07/31 /2023
LICENSE TYPE tSl
B
Date
2/19/2025