411 N PARK VISTA ST (2)Permit Types
BLD ELE ME4m--
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Permit Number: BLD2023-02308
Issued: 05/16/2023
www.anaheim.nef/building
(714)765-0626
Quarter Section: 133
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765.5153
Site Address: 411 N PARK VISTA ST A -D, ANAHEIM, CA 92806
Legal Description: N TR 7219 BLK LOT 3 UN 3-7-B TR 7219 LOT 3 UNIT B
APN: 93227118
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 ($700,000), 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 selfdnsure 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.
I 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 artier and policy are:
Cartier. BERKLEY CASUALTY COMPANY Policy No.: BNLANC0158867 Expiration Date: J/1812024
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 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. /Z-Z
�/� 6 ,
,Si u of p11 nt 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 end
Professions Code, and my license is in hill force and effect.
Contractor tjoddlure Date
NUMBER EXPIRATION DATE
1048449 01/3112025
B. B. B. B. B. C39, C39, C39, C39, C39