1913 S JANETTE LN (2)Permit Types
BLD ELE MEC PLM
Permit Number. BLD2022-04713
Issued: 12101/2022
www.anaheim.net/building
(714)765-0626
Quarter Section: 67
CITY OF ANAHEIM
BUILDING DnRSION
200 S. ANAHEIM BLVD.
(714) 765 -5153
Site Address: 1913 S JANETTE LN, Anaheim, CA 92802
Legal Description: N TR 2489 BLK LOT 170 TR 2489 LOT 170 N 30.96 FT(A
APN:09024434
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
�1 Section 3700 of the Labor Code, for the performance of the work for which this permit is issued.
v' 1 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. BENCHMARK INSURANCE COMPANY Policy No.: CST5022285 Expiration Date: 9/26/2022
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, i(1 should become subject to the workers compensation provisions of Section 3700 of the
Labor Code, I s II forthwith comply with those provisions.
I / IIZZ
Signature of cant Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
I hereby affirm under penalty -of -perjury that-lhem-Isa-construction•lending agency -for the performance of the work for -which -this permitJsassued
(Sec.3097.Civ.C):
Lender's Name:
Lender's 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 d my IlcemseJs in once and effect
Cont t Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE (S)
663409 01/31/2023 8, A, C-8