1314 N BASQUE CIRPermit Types
BLD ELE MEC PLM
X X X X
Permit Number: BLD2022-05763
Issued: 12/06/2022
www.anaheim.net/building
(714)765-0626
Quarter Section: 111
Site Address: 1314 N BASQUE CIR, Anaheim, CA 92806
Legal Description: N TR 1353 BLK LOT 37
APN: 26826104
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(7141765-5153
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 selfansure for wofkees 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 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. CAROLINA CASUALTY INSURANCE COMPANY Policy No.: ONUWC0144084 Expiration Date: 5/18/2023
Name of Agent: Phone No.:
in the performance 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
npensoon laws of California, and agree that, it I should become subject to the worker's compensation provisions of Section 3700 of the
forthwith comply with those provisions.
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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 D RATION•
I hereb affi r the penalt=,,/-
Confactor
of AI
Perjuthat I am I nsed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Profess Code, a d my effect.
Signatu Date
NUMBER EXPIRATION DATE LICENSE TYPE (S)
617148 04/30/2023 B. C54, C33