7001 E COUNTRY CLUB LN (2)Permit Types
BLDELE . MEC PLM
X I X
Permit Number: BLD2023-00725
Issued: 04/07/2023
www.anaheim.net/buiiding
(714)765-0626
Quarter Section: 204
CITY OF ANAHEIM
Site Address: 7001 E COUNTRY CLUB LN, ANAHEIM, CA 92807
Legal Description: N TR 8466 BLK LOT 36
APN:36530101
BUILDING DMSION
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 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 selfuinsure 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.
have and will maintain workees 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. AMERISURE M cy No.: WC54326535 Expiration Date: 41112024
Name of Agent Phone No.:
I certify that in the performance of the work for which this permit is issued, l shall not employ any person in any manner so as to become subject to the
worker's compensation laws of lifomta, and agree that, if I should become subject to the worker's compensation provisions of Section 3700 of the
Labor e 1 shall forthwith y with those provisions.
J � ! ` 2-S
Signature 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 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 li rtes is in full force an
(I
Contractor re
NUMBER EXPIRATION DATE LICENSE TYPE /S)
1062072 01/3112024 C10, C46
Li 19-� 6&5
Date