6010 E HILLCREST CIR (2)Permit Types
BLD ELE MEC PLM
X X
it Numbei:4
Fdrm=023-00650
Issued: 02/16/2023
www.anaheim.net/building
(714)765-0626
Quarter Section: 192
CITY OF ANAHEIM
Site Address: 6010 E HILLCREST CIR, ANAHEIM, CA 92807
Legal Description: N TR 6734 BLK LOT 48
APN: 36312131
BUILDING DIVISION
200 S. ANAHEIM BLVD. {
(714) 765 -5153
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 self4risure for workers compensation, Issued by the Director of Industrial Relations as provided for by
CM 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:
Cartier. ACE AMERICAN INSURANCE COMPANY Policy No.: C51755261 Expiration Date: 101112023
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, N I should become subject to the workers compensation provisions of Section 3700 of the
Labor Code, I shall forthwith comply with those provisions.
Christopher Mc Fadden
Signature of Applicant
Date
2/16/2023
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):
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
Professlons Code, and my license is In full force and effect.
FIXED ENERGY LLC DBA FORME SOLAR ELECTRIC
Contractor Signature
NUMBER EXPIRATION DATE LICENSE TYPE (S)
1056257 06/30/2022 C10
Date
2H6/2023