1182 N KNOLLWOOD CIR (7)Permit Types
BLD ELE MEC PLM
X X
Permit Number: BLD2022-05430
Issued: 03/24/2023
www.anaheim.net/building
(714)765-4626
Quarter Section: 17
CITY OF ANAHEIM
Site Address: 1182 N KNOLLWOOD CIR, ANAHEIM, CA 92801
Legal Description: P BK 71 PG 11 PAR 27
APN:07077209
WORKER'S COMPENSATION DECLARATION:
BUILDING DMSION
200 S. ANAHEIM BLVD.
(714) 76S - S1 S3
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 selfdnsum 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. AMERICAN CASUALTY COMPANY OFREADING ae Policy No.: 7014941871
Expiration Date: 6/1/2023
Name of Agent:
Phone No.:
I certify that in the performance of the work for which this peril 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, it 1 should become subject to the worker's compensation provisions of Section 3700 of the
Labor Code, I shall forthwith comply with those provisions.
Signature of Applicant Dat
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
1 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 afar under the penalty of Perjury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of DMston 3 of the Business and
Professions Code, and my license is in full force and effect.
Contractor Signature
NUMBER EXPIRATION DATE LICENSE TYPE is
1066226 06/30/2024 C10
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