5815 E LA PALMA AVE (3)Permit Types
BLD ELE MEC PLM
X
Permit Number. BLD2023-02549
Issued: 05/23/2023
www.anaheim.nef/building
(714)765-4626
Quarter Section: 184
CITY OF ANAHEIM
Site Address: 5815 E LA PALMA AVE 300, ANAHEIM, CA 92807
Legal Description: T MHP FRNANA MSP 300
APN:89229951
WORKER'S COMPENSATION DECLARATION:
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 -5153
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:
I have and will maintain a certificate of consent to self4nsure 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.
W P 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
liU b this permit is Issued. My workers Compensation Insurance carrier and policy are:
Cartier. CAROLINA CASUALTY INSURANCE COMPAQ Policy No.: BNUWC0157396 Expiration Date: 7/23/2023
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
worker's compensation taws of California, and agree that, If I should become subject to the workers compensation provisions of Section 3700 of the
Labor Code, I shall forthwith comp with those provisions.
Signature of Applican 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 CONTRACTOR'S DECLARATION:
I hereby affirm under the penalty of Perjury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is In full force and effect
Contractor Signature
NUMBER EXPIRATION DATE LICENSE TYPE ISl
1062926 02/29/2024 C39
Date