8860 E CRESTVIEW LNPermit Types
BLD ELE MEC PLM
X X
Permit Number: OLD2022-05354
Issued: 12/21/2022
www.anaheim.net/building
(714)765.4626
Quarter Section: 232
CITY OF ANAHEIM
Site Address: 8860 E CRESTVIEW LN, ANAHEIM, CA 92808
Legal Description: N TR 15129 BLK LOT 9
APN:51405324
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 ATTORNEYS FEES.
I hereby affirm under penalty of perjury one of the following declarations:.
I have and will maintain a certificate of consent to self4nsure for worker's compensation, Issued by the Director of Industrial Relations as provided for by
/7,,, n Section 3700 of the Labor Code, for the performance of the work for which this permit is issued.
�%v f I 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: NATIONAL CASUALTY COMPANY Policy No.: WCC334024A Expiration Date: 6/1/2023
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 I of Califomia, and agree that, if I should become subject to the worker's compensation provisions of Section 3700 of the
Labor Code, I sl with comply with those provisions.
Signature of App cant --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:
1 hereby affirm under the penalty of Perju that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my livens 11 force and effect.
Contractor Signature ' r"Date
NUMBER EXPIRATION DATE LICENSE TYPE (S1
1029644 08/31/2023 B. C10, C46, C39