245 S PERALTA HILLS DR (4)Permit Types
BLD ELE MEC PLM
X
-TPermfi Number: BLD2023-01009
Issued: 03/02/2023
wwmanaheim.neUbuilding
(714)765-0626
Quarter Section: 163
CITY OF ANAHEIM
BUILDING DMSI N
200 S. ANAHEik BLvn. w r•`' " �'
1714)765-5153
Site Address: 245 S PERALTA HILLS DR, ANAHEIM, CA 92807
Legal Description: N TR 58 BLK LOT 3 TR 58 LOT 3 POR OF LOT AS DESC I
APN:36125312
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 self4nsure 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� I 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. TRANSVERSE INSURANCE COMPANY Policy No.: FORWC0000001931 Expiration Date: lr1@024
Name of Agent: Phone No.:
1 certify that in the performance of the work for which this permit Is issued, l 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 workers compensation provisions of Section 3700 of the
Labor Code, I shall forthwith comply with those provisions.
fkw &� . 512l Zd;-3
Signature of Applicant v 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.provlsions 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.
L /U V A&
Contractor Signature If
NUMBER EXPIRATION DATE LICENSE TYPE IS)
818684 04/3012023 C39, B
3 /Z /2023
Date