6970 E AVENIDA DE SANTIAGO (2)Permit Types
BLD ELE MEC PLM
X
Perm@ Number. OLD2022-05720
Issued: 12/06/2022
www.anaheim.netlbuilding
(714)765.4626
Quarter Section: 288
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 755.5153
Sib Address: 6970 E AVENIDA DE SANTIAGOANAHEIM, CA 92807
Legal Description: N TR 10996 BLK LOT 3
APN: 36540111
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 fallowing declarations:
I have and will maintain a certificate of consent to seffansure for worWa compensation. Nsued by the Director of Industrial Relations as provided for by
Section 3700 of the Labor Code, for the Pa.lan. nos of the work for which this permit is issued.
T
Ihave and will mai tain wotu�a 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:
Carter. REGENT INSURANCE COMPANY Pdl y No.: CWC1366721 Expiration Date:
Name oTAgert:
Phone No.:
I certly that in the performance of the work for which this permit is Issued, l shall rpt employ any person In any manner so as to beoortp subject to Oro
workers compensation haws of California, and agree that, Irl should become su*d to the workers compensation provisions of Section 3700 of the
Later Code, I shall forthwith comply with those preNabna.
12/06/22)
Signatureof Appllr�nt— Data
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
I hereby afire under penally of perjury that there is a construction larding agency for the performance of Ire work for which this permit Is issued
(Sec.3097.Clv.C):
Lender's Name:
Lenders Address:
LICENSED CONTRACTOR'S DECLARATION:
I hereby affirm under the penalty of Perjury that 1 am licensed under provisions of chapter 9 (commencing wdtin section 7000) of DMsbo 3 of the Business and
Praresslons Code, and my Ileerw Is In fun farce and effect.
Contractor Signature
NUMBER EXPIRATION DATE LICENSE fS1
915160 0=1=4
12/_06/22
Date