2435 W BALL RD (5)Permit Types
BLD ELE MEC PLM
X
Permit Number: BLD2023.01569
Issued: 04/04/2023
www.anaheim.neUbuilding
(714)765-4626
Quarter Section: 28
CITY OF ANAHEIM
Site Address: 2435 W BALL RD 101-103, ANAHEIM, CA 92804
Legal Description: N TR 3091 BLK LOT 1
APN:12729316
WORKER'S COMPENSATION DECLARATION:
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 ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED
FOR IN SECTION 3706 OR THE LABOR CODE. INTEREST, AND ATTORNEY'S FEES.
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certificate of consent to selfminsure for worker's compensation, issued by the Director of Industrial Relations as provided for by
n J� Section 3700 of the tabor Code, for the performance of the work for which this permit is Issued.
I have and will maintain worker's compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which
this permit is issued. My worker's Compensation insurance carrier and policy are:
Cartier. CAROLINA CASUALTY INSURANCE COMPANY Policy No.: BNUWC0166962 Expiration Date: 111012024
Name of Agent
Phone No.:
I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the
work is compensation laws of California, and agree that, If I should become subject to the worker's compensation provisions of Section 3700 of the
La r Code, I shall forthwith comply with those provisions.
-4 v 2 -C)
F$ plicant 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 Cod , and my license is In full force and effect.
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Copf ctor Si a re
NUMBER EXPIRATION DATE LICENSE TYPE ISl
898367 06/30/2023 C39, C39, C43, C43
Date