1617 S HUMOR DR (3)Permit Types
BLD ELE MEC PLM
X X
Permit Number. BLD2022-05661
Issued: 12/01/2022
www.anaheim.net/building
(714)7654626
Quarter Section: 50
Site Address: 1617 S HUMOR DR, ANAHEIM, CA 92804
Legal Description: N TR 3177 BLK LOT 2
APN:12852205
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 - 5153
PV
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.
JS
I have and will maintain worker's 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.: 9263951 Expiration Date:111912023
7.
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
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.
Jake Shim 12/1/2022
Signature of Applicant Date
I
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
---1-herebyaffirn-under-penallyef-pedury4hat4here•is-a•construction lending agency for the performance -of the-work4orA6ish-thls•permit-is-issued---. - —
(Sec.3097.C1v.C):
Lender's Name:
Lender's 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.
ELIONE ENERGY INC
Contractor Signature
NUMBER EXPIRATION DATE LICENSE TYPE (Sl
1073542 02/28/2023 C10
Date
121112022