811 W JADE WAY (2)Permit Types
BLD
ELE
MEC
PLM
X
X
X
X
Permit Number: BLD2024.03753
Issued: 07/23/2024
www.anaheim.net/building
(714)765-4626
Quarter Section: 61
Site Address: 811 W JADE WAY, Anaheim, CA 92805
Legal Description: N TR 1504 BLK LOT 2
APN: 25511140
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
f714) 765 - 5153
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 ATTORNEYS 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 workers compensation, issued by the Director of Industrial Relations as provided for by
on 3700 of the Labor Code, for the performance of the work for which this permit is issued.
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: CLEAR SPRING PROPERTY AND CASUALTY COMPANY Policy No.: CWCO2950500 Expiration Date: 3/15/2025
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, ff I should become subject to the worker's compensation provisions of Section 3700 of the
ode, shall forthwith comply with those provisions.
ar
Signature of Applicant Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
I hereby of nn 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
Professions Cotle, a m II nse is in full force and effect.
07 h1c �L-y
Contractor Signature" Dates
NUMBER EXPIRATION DATE LICENSE TYPE (S)
952610 09/30/2024