2517 E HILDA PLPermit Types
BLD EE MEC PLM
X X
Permit Number: BLD2022-04647
Issued: 10/24/2022
www.anahe(m.netlbuilding
(714)765.4626
Quarter Section: 124
Site Address: 2517 E HILDA PL, ANAHEIM, CA 92806
Legal Description: N TR 7754 BLK LOT 18
APN:25302318
WORKER'S COMPENSATION DECLARATION:
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(7141766-5163
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 (5100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED
FOR IN SECTION 3706 OR THE LABOR CODE. INTEREST, AND ATTORNEY'S FEES.
1 hereby affirm under penalty of perjury one of the following declarations.
I have and will maintain a certificate of consent to selfansure for workers 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.
I have and will maintain worker's compensation insurance, as required by Section 3700 of the tabor Code, for the performance of the work for which
this permit is Issued. My workers Compensation Insurance carrier and policy are:
Carrier. SIRIUS AMERICA Perky No.: WC10670400 EWratlon Date:10/24/2023
Name of Agent ANDREW MILLER Phone No.: 619-274-8144
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 1 should became subject to the workers compensation provisions of Section 3700 of the
Labor Code,1 shell forthwith comply with those provisions.
10/24/2022
(Signature of Applicant)Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
I hereby a6vm 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: N/A
Lenders Address:
LICENSED CONTRACTOR'S DECLARATION:
I hereby afOrn under the penalty of Perjury that I am licensed under provislons of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license Is in full force and eftecL
A1141v-iter
Contractor Signature
NUMBER EXPIRATION DATE LICENSE TYPE IS
1038437 12/3112023 C10
10/24/2022
Date