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1414 N LAURIE ANN LNPermit Types BLD ELE MEC PLM X Permit Number: BLD2022-04710 Issued: 10/04/2022 www.anaheim.net(building (714)765.4626 Quarter Section: 179 CITY OF ANAHEIM Site Address: 141 N LAURIE ANN LN, ANAHEIM, CA 92807 Legal Description: N TR 5230 BLK LOT 15 APN:35803215 BUILDING DIVISION 200 S. ANAHEIM BLVD. 17141765-6153 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. 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: Cartier: SERVICE AMERICAN INDEMNITY COMPANY Policy No.: SAAWC0001183 Expiration Date: 1/7/2023 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 workers compensation laws of California, end agree that, If I should become subject to the workers compensation provisions of Section 3700 of the La r Code, l shall forthwith comply with those provisions. ©_r// ?fL Signature of Applican 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): Lender's Name: Lender's Address: LICENSED CONTRACTOR'S DECLARATION: 1 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. Con or ig ureCJ Date NUMBER EXPIRATION DATE LICENSE TYPE IS 1003661 05/31/2023 C27, C53