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1235 N BLUE GUM STPermit Types BLD ELE MEC PLM X X Permit Number: BLD2022-05360 Issued: 02/23/2023 www.anaheim.net/building (714)765-4626 Quarter Section: 132 CITY OF ANAHEIM BUILDING DIVISION 200 S. ANAHEIM BLVD. (714) 765 - 5153 Site Address: 1235 N BLUE GUM ST, ANAHEIM, CA 92806 Legal Description: A TR EUCALYPTUS FOREST TR BLK LOT 47 EUCALYPTUS FO APN: 34439405 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. (VF 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 workers Compensation Insurance carrier and policy are: Carrier: FARMINGTON CASUALTY COMPANY Policy No.: UBIW4999082325K Expiration Date: 1/1/2024 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 Calffomia, and agree that, it I should become subject to the workers compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. Mike Fox Mill, g 2/23/23 (Signature of Applicant)Date DECLARATION REGARDING CONSTRUCTION LENDING AGENCY: I hereby affirm under penally 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: Lenders 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 license is in full force and effect. 02/23/2023 (Contractor Signatures Date NUMBER EXPIRATION DATE LICENSE TYPE (S) 933685 06/30/2023 C10, C-7