860 S DUNE STPermit Types
BLD ELE MEWa-
Permit
X Number: BLD2023-01441
Issued: 03/27/2023
www.anaheim.net/building
(714)765-4626
Quarter Section: 124
Site Address: 860 S DUNE ST, ANAHEIM, CA 92806
Legal Description: N TR 3796 BLK LOT 3
APN:25338101
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(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 carder and policy are:
Cartier. EVEREST DENALI INSURANCE COMPANY Policy No.: 1040865 Expiration Date: 10/1/2023
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
w0pes compensation laws of California, and agree that, if 1 should become subject to the workers compensation provisions of Section 3700 of the
Lab r Code, I shall forthwith comply with those provisions.
Of
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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
(Soc.3097.Civ.C):
Lender's Name:
Lender's Address:
LICENSED CONTRACTOR'S DECLARATION:
I hereby affirm undo nalty of Perjury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions Codeand W license is in full force and effect.
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ate
EXPIRATION DATE LICENSE TYPE IS)
1040865 03/31/2023 B. C39