5460 E FULL MOON CTPermit Types
BLD ELE MEC PLM
X X
Permit Number: OLD2022-04933
Issued: 11/30/2022
wwmanaheim.net/building
(714)765-4626
Quarter Section: 181
CITY OF ANAHEIM
Site Address: 5460 E FULL MOON CT, ANAHEIM, CA 92807
Legal Description: N TR 16036 BLK LOT 10
APN:36356110
BUILDING DMSION
200 S. ANAHEIM BLVD.
(714) 765 - 5153
1W
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 (1;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 selfansure for worker's compensation, issued by the Director of Industrial Relations as provided for by
MC Section 3700 of the Labor Code, for the performance of the work for which this permit is issued.
1 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:
Carder. STARNET INSURANCE COMPANY Policy No.: BNL WC0157919 Expiration bate: 9/13/2023
Name of Agent:
Phone No.:
1 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
worker's 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.
Maya Cv1Jic 11/30/2022
Signature of Applicant Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
-hereby affirm under penalty of perjury that there Is a construction4ending•agency4Wh"erfonnance 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
Professlons Code, and my license is In full force and effect.
MILHOLLAND ELECTRIC INC
Contractor Signature
NUMBER EXPIRATION DATE LICENSE TYPE (S)
585514 07/31/2023 C10
Date
11/30/2022