1790 W ORANGE AVE (6)Permit Types .
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Permit Number: BLD2023-01789
Issued: 04/19/2023
www.anaheim.net/building
(714)765-0626
Quarter Section: 48
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CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(7141 765 -5153
Site Address: 1790 W ORANGE AVE, ANAHEIM, CA 92804
Legal Description: N TR 3067 BLK LOT 31
APN: 12824101
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 selfminsum for worker's compensation, issued by the Director of Industrial Relations as provided for by
CR 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 Labor Code, for the performance of the work for which
this permit is issued. My worker's Compensation insurance carrier and policy are:
Cartier. Policy No.: WC58200087023SZ Expiration Date:1/1/2024
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, it I should become subject to the workers compensation provisions of section 3700 of the
Labor Code, I shall forthwith comply with those provisions.
Christian Rose 4/19/2023
Signature of Applicant
Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
1 hereby affirm under penalty of perjury that Mere is a construction lending agency for the performance of the work for which this permit Is Issued
(Sec.3097.Ctv.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.
L A SOLAR SYSTEMS INC 4/19/2023
Contractor Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE (S)
841332 06/30/2022 C46, C10