425 S HARBOR BLVD (10)Permit Types .
BLD ELE MEC PLM
X
Permit Number: BLD2022-04624
Issued: 10/31/2022
www.anaheim.neUbuilding
(714)765-0626
Quarter Section: 73
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(7141765-5153
Site Address: 425 S HARBOR BLVD, ANAHEIM, CA 92805
Legal Description: A TR VINEYARD LOTS BLK LOT F6 VINEYARD LOTS LOT F-
APN:03615004
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 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 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. SERVICE AMERICAN INDEMNITY COMPANY Policy No.: SAMSO468501 Expiration Date: 7/1512023
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
workers compensation laws of California, and agree that, If 1 should become subject to the workers compensation provisions of Section 3700 of Ore
Labor Code, I shall forthwith comply with those provisions.
Signature of lica 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 CONTRACTOR'S DECLARATION:
I hey 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.
o ^ 3/ ^ 2Z
Contractor Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE IS
825022 09/30/2023 C33, B, A. C36, C12, C21, C-8, C-2, C20