7851 E VIEWMOUNT CTPermit Types
BLD ELE MEC PLM
X X
Permit Number. BLD202342190
Issued: 05/05/2023
www.anaheim.net(building
(714)765-4626
Quarter Section: 222
CITY OF ANAHEIM
Site Address: 7851 E VIEWMOUNT CT, ANAHEIM, CA 92808
Legal Description: N TR 12702 BLK LOT 15
APN:36552311
BUILDING DMSION
200 S. ANAHEIM BLVD.
1714)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.
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 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. STATE COMPE §URANCEU Policy No.: 9276323 Expiration Date: 55/19/2023
Name of Agent Phone No.: C19 4Te37
I certify that in the perfomhance 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
terespensation laws of California, and agree that, if 1 should become subject to the worker's compensation provisions of section 3700 of the
s II forthwith comply with those provisions.
0
Signature App nt 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 C e, nd my li is in full force and effect.
050 en.0
chqtractorrpatury Date
NUMBER EXPIRATION DATE LICENSE TYPE (S)
1041842 07/3112024