5620 E PLAZA DE CIELOPermit Types _.
BLD ELE MEC I PLM
X X
Permit Number: BLD2022-05564
Issued: 11/22/2022
www.anaheim.net/building
(714)765-4626
Quarter Section: 186
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765-5153
Site Address: 5620 E PLAZA DE CIELOANAHEIM, CA 92807
Legal Description: N TR 7288 BLK LOT 127 TR 7288 LOT 127 AND LOT 124
APN:36306224
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:
1 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.
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. TRANSVERSE INSURANCE COMPANY Policy No.: 000000222 Expiration Date: IMM023
Name of Agent: Phone No.:
I certify that i s 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
work compen tion laws of California, and agree that, if I should become subject to the workers compensation provisions of Section 3700 of the
r,Code, I s 1 forthwith comply with those provisions.
--jigriftwe of Applicant _ Date
y
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.Crv.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
jProfesslonsCod d my license is in full force and effect.
Contractor ftnature Date
NUMBER EXPIRATION DATE LICENSE TYPE (SI
807029 03/31/2022 B, C36