6130 E ARBORETUM RD (8)Permit Types
BLD ELE MEC PLM
X X
Permit Number: BLD2022-05467
Issued: 12/05/2022
www.anaheim.net/building
(.714)765-4626
Quarter Section: 191
CITY OF ANAHEIM
BUILDING DMSION
200 S. ANAHEIM BLVD.
(714) 765-5153
Site Address: 6130 E ARBORETUM RD, ANAHEIM, CA 92807
Legal Description: N TR 8409 BLK LOT 42 f
APN: 35623213
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: CAROLINA CASUALTY INSURANCE COMPANY Policy No.: BNUWC0152763 Expiration Date: 11/20/2023
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
worker's compensation laws f Califomia, and agree that, if I should become subject to the worker's compensation provisions of Section 3700 of the
-,.,'Pbor Code, I shall forthwi9ffiomply with those provisions.
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 affi nd the penalty of Perjury thItplim licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Profe ns Co , and
y license is in ful and effect.
Signature
NUMBER EXPIRATION DATE
1033340 11/30/2023
LICENSE TYPE (S)
C10, B, C-6