230 S CALLE DIAZ (2)Permit Types
BLD ELE MEC PLM
X X X X
Permit Number: BLD2022-05624
Issued: 01/17/2023
www.tinaheim.net/building
(714)765-4626
Quarter Section: 185
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(7141765-5163
Site Address: 230 S CALLE DIAZANAHEIM, CA 92807
Legal Description: N TR 7769 BLK LOT 71 s.
APN:36318107
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 ATTORNEYS FEES.
I hereby affirm under penalty of perjury one of the following declarations:
1 have and will maintain a certificate of consent to selfansure for worker's compensation, issued by the Director of Industrial Relations as provided for by
n / Section 3700 of the tabor 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. STATE COMPENSATION INSURANCE FUND Policy No.: 92566AIS Expiration Date:a 0 3
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
worker's compensation laws of California, and agree that, it I should become subject to the workers compensation provisions of Section 3700 of the
Labor Code, I shall forthwith ply with those provisions.
Oi 1 i�Iz
Signat Ap ' nt Date
0
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:
Lenders 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 and
Professions Code, ann
d my licesl
$ To 17
ict.
Contractor SIgN19x"-- — '-TJ -
NUMBER EXPIRATION DATE LICENSE TYPE (S)
1052090 06/30/2023
611 tal L3
`Date