310 S BRIDGE VIEW DR (2)Permit Types
BLD ELE MEC PLM
X X X I X
Permit Number: OLD2023-00352
Issued: 02/16/2023
wwmanaheim.net/building
(714)765-4626
Quarter Section: 203
CITY OF ANAHEIM
'Site Address: 310 S BRIDGE VIEW DR, ANAHEIM, CA 92808
-Legal Description: N TR 8560 BLK LOT 72 '
APN:35635409
WORKER'S COMPENSATION DECLARATION:
L BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 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 seff4nsure 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.
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 worker's Compensation insurance carrier and policy are:
Cartier. EVEREST PREMIER INSURANCE COMPANY Policy No.: 7600001365221 Expiration Date: 31/2023
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
workers compensation laws of Cali mia, and agree that, if I should become subject to the workers compensation provisions of Section 3700 of the
Labor Code, I shall forthwith comply th those provisions.
natup,6f 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:
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 Cade, and my license is n 7rce end effect.
2
on or Signatu Date
NUMBER EXPIRATION DATE LICENSE TYPE ISl
665114 02/28/2023
Il