936 E SANTA ANA ST (4)Permit Types _ _
BLD ELE MEC PLM
X
Permit Number: BLD2022-04877
Issued: 12/12/2022
www.6naheim.net/building
(714)765.4626
Quarter Section: 93
CITY OF ANAHEIM
BUILDING DMSION
200 S. ANAHEIM BLVD.
1714) 765-5153
Site Address: 936 E SANTA ANA ST, Anaheim, CA 92805
Legal Description: N TR 18101 BLK LOT 8 UN HOLD LOT 8 OF TRACT 18101;
APN:03731036
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 selfansure 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.
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:
Carver. ACCREDITED SURETY AND CASUALTY COMPANY INC Policy No.:1AUICA160129863300 Expiration Date: 212112023
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 laws of Califomia, 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.
SignatupCoif Applicant
17074 ZZ
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 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.
Contractor nature
NUMBER EXPIRATION DATE LICENSE TYPE (Sl
1019174 10/3112024
Date