2222 E HOWELL AVE (3)Permit Types
BLD ELE MEC PLM
X
Permit Number: BLD2022-06615
Issued: 12107/2022
www.anaheim.net/building
(714)7654626
Quarter Section: 117
Site Address: 2222E HOWELL AVE, ANAHEIM, CA 82806
Legal Description: P BK 65 PG 5 PAR 2
APN: 25353105
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 - 6163
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 (5100,000), 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 penally 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.
z
I have and will maintain workers compensation Insurance, as required by Section 3700 o1 the Labor Code, for the performance of the work for which
this permit is Issued. My workers Compensation insurance carrier and policy are:
Cancer: GREAT DIVIDE INSURANCE COMPANY Policy No.: WCA1524927 Expiration Date: 11112023
Name of Agent: Apollo General Insurance Phone No.: 707-996-2912
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 Cellomia, and agree that, if I should become subject to the workers compensation provisions of Section 3700 of the
/La1b_or Code, I shall forihwilh comply with those provisions.
L�� p6a& 12/07/2022
Signature of Applicant Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
I hereby affirm under penally 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:
Lenders Address:
LICENSED CONTRACTOR'S DECLARATION:
1 hereby effkm under the penalty of Perjury that I am licensed under provisions of chapter 9 (commencing with Section 7000) or Division 3 of the Business and
Professions Code, e d my license Is In lull force and effect.
12/07/2022
Contractor Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE Is
252618 0713112024 C21, 8, HAZ