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