920 S LAKE SUMMIT DR (4)Permit Types
BLD ELE MEC PLM
X
Permit Number: BLD2023-02547
Issued: 05/23/2023
www.anaheim.net/building
(714)765-0626
Quarter Section: 217
CITY OF ANAHEIM
Site Address: 920 S LAKE SUMMIT DR, ANAHEIM, CA 92807
Legal Description: N TR 8515 BLK LOT 3
APN:36519203
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(7141 765 -5153
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.
1 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.
1 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 worker's Compensation insurance carrier and policy are:
Cartier. CAROLINA CASUALTY INSURANCE COMPANY Policy No.: SNUWC0159703 Expiration Date: 4/29/2024
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
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
Labor Code, l shall forthwith comply with those provisions.
YVI-atuMAfApipli 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:
Lenders Address:
LICENSED CONTRACTOR'S DECLARATION:
I hereby affirm under the penalty of Periury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my licens II force and effect.
-Contrac Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE IS)
1021491 12/31/2024 B. C39