407 S COUNTRY HILL RD (3)Permit Types
BLD ELE MEC PLM
X X
Permit Number: BLD2023-00074
Issued: 02/03/2023
www.anaheim.net/building
(714)765-4626
Quarter Section: 203
CITY OF ANAHEIM
Site Address: 407 S COUNTRY HILL RD, ANAHEIM, CA 92808
Legal Description: P BK 28 PG 29 PAR 2
APN: 35617102
BUILDING DIVISION
200 S. ANAHEIM BLVD
(7141 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 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 selfinsure 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 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:
Cartier. CAROLINA CASUALTY INSURANCE COMPANY Policy No.: 8NUWC0156728 Expiration Date: 5/11,2023
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
workers compensation laws of California, and agree that, if I should become subject to the workers compensation provisions of Section 3700 of the
/I bor Cod , I shall forthwith comply with those provisions.
gnature of.Applicant
0/50
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:
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
Profession e, d my nse Is in full force and effect.
a/3I�
Contractor Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE IS)
1008748 11/30/2021