1254 N AETNA ST (4)Permit Types
BLOT ELE FEC PLM
X I X
Permit Number. BLD2022-04636
Issued: 11/09/2022
www.anaheim.neUbuilding
(714)765-4626
Quarter Section: 30
Site Address: 1254 N AETNA ST, ANAHEIM, CA 92801
Legal Description: N TR 2288 BLK LOT 30
APN:07133208
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(7141 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 workers compensation, issued by the Director of Industrial Relations as provided for by
FG 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:
Cartier. STATE COMPENSATION INSURANCE FUND Policy No.: 9296034 Expiration Date: 4/1012023
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 workers compensation provisions of Section 3700 of the
Labor Code, I shall forthwith comply With those provisions.
Felicia Gonzalez 11/911022
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 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.
SUNGRID SOLAR
Contractor Signature
NUMBER EXPIRATION DATE LICENSE TYPE (S)
1037212 03/31/2024 B. C10
Date
11/9/2022