118 S BETH CIR (4)Permit Types
•BLD ELE MEC PLM
X X X X
Pelssell Number. OLD2022-05012
Issued: 03/02/2023
www.anaheim.netlbuilding
(714)765-4626
Quarter Section: 133
Site Address: 118 S BETH CIR, ANAHEIM, CA 92806
Legal Description: N TR 7088 BLK LOT 39
APN:26801239
CITY OF ANAHEIM
BUILDING DMSION
200 S. ANAHEIM BLVD. -
(714) 765-5153
WORKER'S COMPENSATION DECLARATION:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES
AND CML 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 self -insure for workers 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..� I have and will maintain workers compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which
this permit is issued. My workers Compensation insurance carrier and policy are:
Carrier. EVEREST PREMIER INSURANCE COMPANY Policy No.: 7600022236221 Expiration Date: 31812023
Name of Agent: Phone No.:
I codify that in the performance of the work for which this permit is issued, I shag not employ any person in any manner so as to become subject to the
workers compensation laws of California, and agree that, ff I should become subject to the workers compensation provisions of Section 3700 of the
Code; I°shat orthwith comply with those provisions.
C/
V? J 2v -,7
Sign atur 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):
Lenders Name:
Lenders Address:
LICENSED CONTRACTOR'S DECLARATION:
1 hereby affirm under the penalty of Pedury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions Code, a d my license is in full force and effect.
Co c r Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE (S)
990408 0212812022