5208 E GATEWOOD LNPermit Types _.
BLD . ELE MEC I PLM
X
Permit Number" 2023-00238 a,
Issued: 02/23/2023
www.anaheim.net/building
(714)765-4626
Quarter Section: 174
CITY OF ANAHEIM
Site Address: 5208 E GATEWOOD LN, ANAHEIM, CA 92807
Legal Description: N TR 5999 BLK LOT 53
APN:36110132
BUILDING DPASION
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.
1 hereby affirm under penalty of perjury one of the following declarations:
1 have and will maintain a certificate of consent to selfinsure 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.
1 have and will maintain wofkees 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:
Cartier: CLEAR SPRING PROPERTY AND CASUALTY COMPANY Policy No.: CWC00092901 Expiration Date: 8/16/2023
Name of Agent: Phone No.:
I certify Pat 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
ffsation laws of California, and agree that, if I should become subject to the workers compensation provisions of Section 3700 of the
all forthwith comply with those provisions. 12d
Signatu 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):
Lenders Name:
Lenders Address:
LICENSED
1 hereby affix
Professions 1'
CTOWS DECLARATION:
penalty of Perjury that I am licensed under provisions of chapter 9 (commencing With Section 7000) of Division 3 of the Business and
my license is in full force and effect.
Signature
NUMBER EXPIRATION DATE LICENSE TYPE (S)
1026416 05/31/2023
2I `L3 JZ3
Date