1664 S BROOKHURST ST (3)Permit Types
BLD I ELE I MEC PLM
X I X
Permit Number. BLD2023-01921
Issued: 04/27/2023
www.anaheim.net/building
(714)765-4626
Quarter Section: 43
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(7141 765 - 5153
Site Address: 1664 S BROOKHURST ST, ANAHEIM, CA 92804
Legal Description: S TWP 4 RGE 10 SEC 20 SEC 20 T 4 R 10 N 175 FT S 5
APN:12847233
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:
1 have and will maintain a certificate of consent to seltansure 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 workeee 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. LM INSURANCE CORPORATION Policy No.: WA561DBIITBZ6013 Expiration Date. 1/1/2024
Name of Agent: Phone No.:
1 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 laws of California, and agree that, if I should become subject to the worker's compensation provisions of Section 3700 of the
Labor Code, I shall forthwith comply with those provisions. % n
Si n lure of Applic� 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):
Lender's Name:
Lender's Address:
LICENSED CONTRACTOR'S DECLARATION:
I hereby affirm under the penalty of Perjury that 1 am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
;Pro4fessons Code, and my license Is in full force and effect
-�Coor 131:1,110
NUMBER EXPIRATION DATE LICENSE TYPE ISl
671513 05/31/2023 A, C10, S. HAZ
i�, z
,Date