2509 W BERYL AVEPermit Types
BLD ELE MEC PLM
X
Permit Number: BLD2022-05862
Issued: 12112/2022
www.anaheim.net/building
(714)765-0626
Quarter Section: 27
Site Address: 2509 W BERYL AVE, ANAHEIM, CA 92804
Legal Description: N TR 5556 BLK LOT 12
APN: 12716325
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 - 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 ATTORNEYS FEES.
I hereby affirm under penalty of perjury one of the following declarations:.
1 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.
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: Polio No.: Expiration Date:
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
worker's compensation taws of California, and agree that, if I should become subject to the workefs compensation provisions of section 3700 of the
Labor Code, l shall forthwith comply With those provisions.
1212- .2 2
Signature of Applicant Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
1 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:
1 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
PT slon
salon Code, and my license is in full tares and effect
Contractor Signature Date
NUMBER
1047203
EXPIRATION DATE
11/30/2022
LICENSE TYPE (S)
C10