1664 S BROOKHURST ST (2)Permit Types
BLD ELE MEC PLM
X X X X
Permit Number. OLD2022.04902
Issued: 04/27/2023
www.anaheim.net/building
(714)765.4626
Quarter Section: 43
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 -5153
Site Address: 1664 S BROOKHURST ST, ANAHEIM, CA 92804
Legal Description: S TWP 4 RGE 10 SEC 20 SEC 20 T 4 R 10 N 175 FT S 5
APN: 12847233
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.
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 workers Compensation Insurance carrier and policy are:
Cartier. LM INSURANCE CORPORATION Policy No.: WA561DBOTOB013 Expiration Date: 11112024
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 Califomia, and agree that, if I should become subject to the worker's compensation provisions of Section 3700 of the
Labor Code, forthwith comply with those provisions.
4re of 4pkint Dae
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.Crv.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 full force and effect.
n(ract6r'Si§r1at6r6 bate
NUMBER EXPIRATION DATE LICENSE TYPE (S)
671513 05/31/2023 A. C10, B, HAZ