8261 E BLACKWILLOW CIR 200-206Permit Types
BLD ELE MEC PLM
X
Permit Number. BLD2022-05014
Issued: 11/07/2022
wwmanaheim.net/buiiding
(714)765-4626
Quarter Section: 220
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 - 5153
Site Address: 8261 E BLACKWILLOW CIR 200-206, ANAHEIM, CA 92808
Legal Description: N TR 12994 BLK LOT 1 TR NO 12994 PORS OF LOTS 1 AN
APN:35430111
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 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 wofker'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 workers Compensation insurance carrier and policy are:
Cartier. PREFERRED PROFESSIONAL INSURANCE COMPANY Policy No.: ON0900104 Expiration Date: 7/1/2023
Name of Agent:. Phone No.:
I 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, l shall fe with comply with those provisions.
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):
Lender's Name:
Lender's Address:
LICENSED CONTRACTOR'S DECLARATION:
I hereby affirm under the penalty of Perjury that 1 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.
tractor Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE ISl
359679 11/30/2023 B, B. B. B, 8