1786 S CARNELIAN ST (3)Permit Types
BLD ELE MEC PLM
X X
Permit Number: OLD2023-02245
Issued: 05/09/2023
www.anaheim.net/building
(714)765.4626
Quarter Section: 57
CITY OF ANAHEIM
Site Address: 1786 S CARNELIAN ST, ANAHEIM, CA 92802
Legal Description: N TR 2210 BLK LOT 2
APN: 12939506
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 ATTORNEY'S FEES.
I hereby affirm under penalty bf perjury one of the following declarations:
I have and will maintain a certificate of consent to selfinsure for workers 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 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. Policy No.: Expiration Date:
Name of Agent Phone No.:
�j 1 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 tothe
workers compensa .an laws of California, and agree that, N I should become subject to the workers compensation provisions of Section 3700 of the
Labor Code, I s fortlhvrith comply with those provisions.
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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):
Lenders 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 11 nse Is in full force and effect.
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ContractorySignature Date
NUMBER EXPIRATION DATE LICENSE TYPE ISl
872323 01/31/2023 B. C46, C10