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1507 W CARA DRPermit Types BLD ELE MEC PLM X Permit Number. BLD2022-05318 Issued: 11/10/2022 www.anaheim.net/building (714)765-0626 Quarter Section: 87 Site Address: 1507 W CARA DR, ANAHEIM, CA 92805 CITY OF ANAHEIM BUILDING DMSION 200 S. ANAHEIM BLVD. (714) 765 -5153 Legal Description: S TWP 4 RGE 10 SEC 22 T4S R1 OW POR OF SEC 22 & 23 APN:08221406 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 RC 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 worker's Compensation insurance carrier and policy are: Carrier. TRANSVERSE INSURANCE COMPANY Policy No.: 0000001760 Expiration Date: 121112022 Name of Agent: Phone No.: I 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 workers 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. Russell Collins 11/10/2022 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): Lenders 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 Professions Code, and my license is in full force and effect. EV PROS INC Contractor Signature NUMBER 1022572 EXPIRATION DATE 01/31/2023 LICENSE TYPE (SI C10 11/10/2022 Date