1011 S EAST ST (11)Permit Types _
BLD ELE MEC PLM
X X
Permit Number. BLD2023-01358
Issued: 05/19/2023
www.anaheim.net/building
(714)7654626
Quarter Section: 95
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765-5153
Site Address: 1011 S EAST ST, ANAHEIM, CA 92805
Legal Description: A TR ANAHEIM EXT BLK LOT 21 ANAHEIM EXT LOT 21 POR
APN: 23410114
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 far 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 end policy are:
Cartier.. HARTFORD ACCIDENT AND INDEMNITY COMPANY Policy No.: 30WVWO0267 Expiration Date: 1/31/2024
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
workers compensation laws of California, and agree that, H I should become subject to the worker's compensation provisions of Section 3700 of the
Labor Code all with comply with those provisions.
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�S nature of Applica 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 herby affirm under the penalty of Pedury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of DMsion 3 of the Business and
P essions Code, and my license is rce and effect
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Coractor Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE (S)
817191 02/28/2023 A. C10, C46.8