1024-1026 E ARLEE PLPermit Types
BLD ELE MEC I PLM
X I X
Permit Number: BLD2022-04874
Issued: 01/10/2023
www.anaheim.net/building
(714)7654626
Quarter Section: 95
CITY OF ANAHEIM
Site Address: 1024-1026 E ARLEE PL, ANAHEIM, CA 92805
Legal Description: N TR 3315 BLK LOT 6
APN: 23410110
WORKER'S COMPENSATION DECLARATION:
BUILDING DMSION
200 S. ANAHEIM BLVD.
(7141 765 -5153
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 selfansure 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 carrier and policy are:
Cartier: OAK RIVER INSURANCE COMPANY Policy No.: RAWC123556 Expiration Date: 9/10/2022
Name of Agent: Phone No.:
1 certify that in the performance of the work for which this permit is issued, l shall not employ any person in any manner so as to become subject to the
worker's 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 co y with those provisions.
Si ature of Appl- 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:
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, and my license is in II force and effect.
ontractor Signal
NUMBER EXPIRATION DATE LICENSE TYPE (S)
939057 10/31/2023 C10, C10, B. B
1 � 202 3
Date