8140 E SANTA ANA CANYON RD (7)Permit Types
BLD ELE MEC PLM
X
Permit Number:'gLD2022-05260
Issued: 02/03/2023
www.anaheim.net/building
(714)765-4626
Quarter Section: 213
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 -5153
Site Address: 8140 E SANTA ANA CANYON RD 176, Anaheim, CA 92808
Legal Description: P BK 255 PG 1 PAR 11 P M 255-1 PAR 11 POR OF PAR
APN: 35445128
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.
1 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.
1 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 tamer and policy are:
Cartier. STATE COMPENSATION INSURANCE FUND Policy No.: 9296746 Expiration Date: 2112/2023
Name of Agent:
Phone No.:
I certify that in the AArI nuance 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
ork oomperisatin laws of California, and agree that, if I should become subject to the worker's compensation provisions of Section 3700 of the
r Code, shall orthwith comply with those provisions. r7
ignatu plicant 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:
Lenders Address:
LICENSED CONTRI
I hereby affirm undeathe
Professio z
ContractorNgnatun
loor
NUMBER
1073980
DECLARATION:
of Pedury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
e is in full force and effect.
EXPIRATION DATE LICENSE TYPE (S)
03/31/2023
2 -1 -�
Date