823 S BEACH BLVD (6)Permit Types
BLD ELE MEC PLM
X
Permit Number: BLD2022-05909
Issued: 03/31/2022
www.anaheim.net/building
(714)765-0626
Quarter Section: 10
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 - 5153
Site Address: 823 S BEACH BLVD, ANAHEIM, CA 92804
Legal Description: S TWP 4 RGE 11 SEC 14 SEC 14 T 4 R 11 N 385 FT E1/
APN: 07916414
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
�j this permit is issued. My worker's Compensation insurance carrier and policy are:
�If Cartier. GREAT DIVIDE INSURANCE COMPANY Policy No.: WCA1524927 Expiration Date:11112023
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
wo er pe laws of California, and that, it 1 should become subject to the worker's compensation provisions of Section 3700 of the
r Co she rthwith co ply wi rovls ns.
SI a re of Applicant 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 P uryt1fttnnsed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions e, an y license1s ct.
Contractor gignature Date
NUMBER EXPIRATION DATE LICENSE TYPE (S)
252618 07/31/2024 C21, B, HAZ