1821 W CRESTWOOD LN (5)Permit Types
BLD ELE MEC PLM
X
Permit Number: BLD2022-05389
Issued: 11/14/2022
www.anaheim.net/building
(714)765-4626
Quarter Section: 50
CITY OF ANAHEIM
Site Address: 1821 W CRESTWOOD LN, ANAHEIM, CA 92804
Legal Description: N TR 2222 BLK LOT 42
APN: 12855105
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 ($700,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED
FOR IN SECTION 3706 OR THE LABOR CODE. INTEREST, AND ATTORNEY'S FEES.
1 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.
CI 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. EVEREST PREMIER INSURANCE COMPANY Policy No.: 7600022744221 Expiration Date:01 /12023
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
I
workers compensation laws f California, and agree that, if I should become subject to the workers compensation provisions of Section 3700 of the
hall Labor Code, I sforthth lmDiv with those orovisions.
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 ONTRACTOR'S DECLARATION:
I hereby affi oder the penalty of Perjury that m licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions e, and m 'cense is In full a effect.
Date
NUMBER EXPIRATION DATE LICENSE TYPE (S)
927155 01/312023 C15