1059 S MOUNTVALE CTPermit Types
BLD ELE MEC PLM
X
Permit Number: OLD2023-02132
Issued: 05/02/2023
www.anaheim.net/building
(714)765-0626
Quarter Section: 216
CITY OF ANAHEIM
Site Address: 1059 S MOUNTVALE CT, ANAHEIM, CA 92808
Legal Description: N TR 12701 BLK LOT 117
APN:36553124
BUILDING DMSION
200 S. ANAHEIM BLVD.
(714) 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 ATTORNEYS 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 workers 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 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: SAFETY NATIONAL CASUALTY CORPORATION Policy No.: SP4068090 Expiration Date: 3/1/4024
Name of Agent: ��l i b a Phone No.: ` c, —Z %) —
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 taws of California, and agree that, if I should become subject to the workers compensation provisions of Section 3700 of the
Labor Code, I shall forthwith comply with those provisions.
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Signature of Appii ni 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 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 Sign dire Date
NUMBER EXPIRATION DATE
602331 09/30/2024
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B. 1312, C-2, C39, C-6, C17, C36, D34.041, D24, C10