1806 E ALCOVE WAY (2)Permit Types
BLD ELE MEC PLM
X
rPermit Number: BLD202340870
Issued: 02122/2023
www.anaheim.net/building
(714)765-4626
Quarter Section: 105
Site Address: 1806 E ALCOVE WAY, ANAHEIM, CA 92805
Legal Description: N TR 6409 BLK LOT 100
APN: 23406214
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIBA
(714) 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 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 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: ACE AMERICAN INSURANCE COMPANY Policy No.: WCUC68916446 Expiration Date: 3/1/2023
Name of Agent: Phone No.:
I certify th 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
works mpensatio of California, and agree that, if I should become subject to the worker's compensation provisions of Section 3700 of the
Le r Cod I shall rthwlth m 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 CO CTOR'S DECLARATION:
1 hereby af8 nder the pena of Perjury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professlo Cod and�mytli rise is full fprce and effect.
Contractor Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE ISI
602331 09/30/2024 C10, B. D12, C-2, C39, C-6, C17, C36, D34, D41, D24