422 N BETH ST (3)Permit Types
BLD ELE MEC PLM
X X
Permit Number: BLD2023-01344
Issued: 04/07/2023
www.anaheim.net/building
(714)765.4626
Quarter Section: 133
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(7141 765 - 5153
Site Address: 422 N BETH ST B, ANAHEIM, CA 92806
Legal Description: N TR 7218 BILK LOT 3 UN 3-4-B TR 7218 LOT 3 UNIT 3-
APN: 93204150
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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.
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 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.
EM
I have and will maintain wofkees 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 carder and policy are:
Cartier: CAROLINA CASUALTY INSURANCE COMPANY Policy No.: BNL WC0157832 Expiration Date: 9/6/2023
Name of Agent: Phone No.:
I 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 comply With those provisions.
Emily Mills 4/7/2023
Signature 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:
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 full force and effect.
SMART PHASE ENERGY
Contractor Signature
NUMBER EXPIRATION DATE LICENSE TYPE (S)
1054456 06/30/2023 C10, C39
Date
4/7/2023