208 N CARLETON AVEPermit Types
BLD ELE MEC PLM
X X
Permit Number. BLD2023-01985
Issued: 04/28/2023
www.anaheim.net/building
(714)765-4626
Quarter Section: 62
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714)765 -5153
Site Address: 208 N CARLETON AVE, ANAHEIM, CA 92801
Legal Description: A TR SUMMERFIELD & OPPENHEIMERS SUB BLK 5 LOT 29 S
APN:25503115
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 deciandions:
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.
MH
I have and will maintain workers 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:
Carrier. TECHNOLOGY INSURANCE COMPANY INC Policy No.: TWC4102876 Expiration Data. 41112024
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 laws of California, and agree that, if I should become subject to the workers compensation provisions of Section 3700 of the
Labor Code, I shall forthwith comply with those provisions.
Mark Helisund 4/28/2023
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):
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 DNision 3 of the Business and
Professions Code, and my license is in full force and effect.
BETTER EARTH ELECTRIC INC 4/2812023
Contractor Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE (S)
1024460 03131/2025 C10
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