7668 E HOLLOW OAK RD (4)Permit Types
BLD I ELE I MEC PLM
X
Permit Number: BLD2022-05090
Issued: 10/26/2022
www.anaheim.nebbuilding
(714)765-0626
Quarter Section: 215
CITY OF ANAHEIM
Site Address: 7668 E HOLLOW OAK RD, ANAHEIM, CA 92808
Legal Description: N TR 12688 BLK LOT 85
APN: 35449404
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(7141765-5153
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.
1 hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certificate of consent to selfainsure for worker's compensation, issued by the Director of Industrial Relations as provided for by
JB Section 3700 of the tabor 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 worker's Compensation Insurance carrier and policy are:
Cartier. SECURITY NATIONAL INSURANCE COMPANY Policy No.: SWC1377162 Expiration Date: 3/23/2023
Name of Agent: Phone No.:
I certify that In the performance of the work for which this permit is issued, l 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 workers compensation provisions of Section 3700 of the
Labor Code, I shall forthwith comply with those provisions.
Jason Brower _ - 10/26/2022
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 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.
ECO -TECH ELECTRICAL SERVICES INC
Contractor Signature
NUMBER
EXPIRATION DATE
03/31/2024
LICENSE TYPE ISI
C10
10/26/2022
Date