1019 S SUMMER BREEZE LN (3)Permit Types
BLD ELE MEC PLM
X -
x
Permit Number: OLD2022-05198
Issued: 11/03/2022
www.anaheim.net/building
(714)785-4626
Quarter Section: 227
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(7141765-5153
Site Address: 1019 S SUMMER BREEZE LN, ANAHEIM, CA 92808
Legal Description: N TR 13515 BLK LOT 37 TRACT 13515 LOT 37 POR OF LO
APN: 35440124
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 selfwInsure 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.
JR
1 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. STARNET INSURANCE COMPANY Policy No.: BNUWC0156509 Expiration Date: 4/0/2023
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 California, and agree that, if I should become subject to the worker's compensation provisions of Section 3700 of the
Labor Code, I shall forthwith comply with those provisions.
Jesse Raymond 11/3/2022
Signature of Applicant
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):
Lenders Name:
Lender's Address:
LICENSED CONTRACTOR'S DECLARATION:
I hereby affirm under the penalty of Pedury 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 -
ORANGE COUNTY CONTRACTING SERVICES 11/3/2022
Contractor Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE IS)
1023627 02/28/2023 B, C10