2222 S NAUTICAL STPermit Types
BLD ELE MEC PLM
X X
Permit Number. BL on-omt
Issued: 12/02/2022
www.anaheim.net/building
(714)765-4626
Quarter Section: 99
Site Address: 2222 S NAUTICAL ST, ANAHEIM, CA 92802
Legal Description: N TR 3945 BLK LOT 29
APN:13742139
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 ATTORNEYS FEES.
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certificate of consent to selfansure 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 workers 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. STARR INDEMNITY &: LIABILITY COMPANY Policy No.: 1000005080 Expiration Date: 7!2612023
_. Name of Agent:'Phone No. - —
I certify that in the performance of the work for which this permit is issued, I shell not employ any person in any manner so as to become subject to the - -
workers compensation laws of California, and agree that, it I should become subject to the workers compensation provisions of Section 3700 of the -
bor Code, l shall forthwith comply with those provisions.
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07
Signature o p i � .., _..._.-_=-_--
Date --- -
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY: -
rfenalty-of"qury4hat there-is"a constructlen-lendingagem Is -permit is Issued _ -
(Sec.3097.Civ.C):
Lender's Name:
Lender's 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 e, an my license is in full force and effect. - - -
Contractor Si Date
NUMBER EXPIRATION DATE LICENSE TYPE IS
976336 09/30/2024 C10, C46