715 S RESH STPermit Types
BLD ELE MEC PLM
X X
Permit Number. BLD202342031
Issued: 04/27/2023
www.anaheim.net/building
(714)765-4626
Quarter Section: 73
Site Address: 715 S RESH ST, ANAHEIM, CA 92805
Legal Description: N TR 1453 BLK LOT 18
APN: 03617118
WORKER'S COMPENSATION DECLARATION:
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
11711411765-51153
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
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 carrier and policy are:
Cartier. CLEAR SPRING PROPERTY AND CASUALTY COMPANY Policy No.: CWC01666600 Expiration Date: 2/6/2024
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 CW, I shall forthwith comply with those provisions.
Sign piicant
Date
/Z623
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
ProfessionsCode, and nse is In full force and effect.
fZ� 6Y/12-11� Z G
Cont glulv Date
NUMBER EXPIRATION DATE LICENSE TYPE (SI
1044735 10/31/2024