1723 W CARA DRPermit Types
BLD ELE MEC PLM
X
Permit Number: BLD2022-05233
Issued: 11/03/2022
www.anaheim.net/building
(714)765-0626
Quarter Section: 87
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 - 5153
Site Address: 1723 W CARA DR, ANAHEIM, CA 92805
Legal Description: S TWP 4 RGE 10 SEC 22 SEC 22 POR OF US R10W AND T
APN: 08221405
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:
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. ACE AMERICAN INSURANCE COMPANY Policy No.: 051749030 Expiration Date:101112023
Name of Agent:
Phone No.:
I certify that in the perfo ce 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
workers compem on laws of California, and agree that, if I should become subject to the worker's compensation provisions of Section 3700 of the
Labor Codi!'014hafl forthwith comply with those provislons.
Of
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:
Lenders 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 d effect.
Contractor Signal Date
NUMBER EXPIRATION DATE LICENSE TYPE ISl
933396 05/31/2022 C10