516 N PLANTATION PLPermit Types
BLD ELE MEC PLM
X X
Permit Number: BLD2022-04767
Issued: 12/21/2022
www.anaheim.net/building
(714)765-0626
Quarter Section: 122
CITY OF ANAHEIM
Site Address: 516 N PLANTATION PL, ANAHEIM, CA 92806
Legal Description: N TR 3614 BLK LOT 52
APN:26830232
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 ATTORNEYS FEES.
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certificate of consent to self4nsure for worker's compensation, issued by the Director of Industrial Relations as provided for by
MM 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 carter and policy are:
Cartier: TECHNOLOGY INSURANCE COMPANY INC Policy No.: TWC4102876 Expiration Date: 4/15/2023
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
worker's compensation laws of California, and agree that, If 1 should become subject to the worker's compensation provisions of Section 3700 of the
Labor Code, I shall forthwith comply with those provisions.
Maggie Matthews 1221/1022
Signature of Applicant
Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
1 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:
Lenders 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
Professions Code, and my license Is in full force and effect.
BETTER EARTH ELECTRIC INC
Contractor Signature
NUMBER
1024460
EXPIRATION DATE
03/31/2023
LICENSE TYPE (S)
C10
Date
12/21/2022