1744 W GLEN AVEPermit Types _
BLD ELE MEC PLM
X
Permit Number: BLD202342202
Issued: 05/08/2023
www.anaheim.net/building
(714)765.4626
Quarter Section: 44
Site Address: 1744 W GLEN AVE A -D, Anaheim, CA 92801
Legal Description: N TR 3812 BLK LOT 3
APN:07255303
WORKER'S COMPENSATION DECLARATION:
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
1714) 765.5153
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 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.
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 workefs Compensation Insurance carrier and policy are:
Cartier. CLEAR SPRING PROPERTY AND CASUALTY COMPANY Policy No.: CWC00001001 Expiration Date: 6/5/2023
Name of Agent: Phone No.:
I certiy 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 laws of California, and agree that, If I should become subject to the worker's compensation provisions of Section 3700 of the
/ loch Code, I she
11/forthwith comply with those provisions.
C wZ
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 license is in full force and effect.
Contractor Signature
NUMBER EXPIRATION DATE
1054536 06/30/2023
LICENSE TYPE (S)
B. B, B. B, B. C33, C33, C33, C33, C33
Date