409 N JEANINE DR (3)Permit Types
BLD ELE MEC PLM
X
Permit Number. BLD2023-02312
Issued: 05/11/2023
www.anaheim.net(building
(714)765.4626
Quarter Section: 133
Site Address: 409 N JEANINE DR, Anaheim, CA 92806
Legal Description: N TR 7218 BLK LOT UN HOLD
APN: 26817101
WORKER'S COMPENSATION DECLARATION:
CITY OF ANAHEIM
BUILDING DMSION
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 CML 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 self4nsure for worker's compensation, Issued by the Director of Industrial Relations as provided for by
_Section 3700 of the Labor trade, for the performance of the work for which this permit is Issued.
Cr 1 have and will maintain workers compensation insurance, as required by Section 3700 of the tabor Code, for the performance of the work for which
this permit Is issued. My workers Compensation insurance carrier and policy are:
Cartier. BERKLEY CASUALTY COMPANY Policy No.: BNUWC0156867 Expiration Date: 1/16/2024
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 I should become subject to the workers compensation provisions of Section 3700 of the
loch Cade, I shall with comply with those provisions.
5--11-,23
Signature of nt Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
1 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:
Lenders Address:
LICENSED CONTRACTOR'S DECLARATION:
1 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.
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Contractor SignaWe Date
NUMBER EXPIRATION DATE LICENSE TYPE (Sl
1046449 01/31/2025 B. C39