2502 E ROMNEYA DR (10)Permit Types
BLD ELE MEC PLM
X
Permit Number: BLD202340885
Issued: 02/23/2023
www.anaheim.netlbuilding
(714)765-4626
Quarter Section: 111
Site Address: 2502 E ROMNEYA DR, Anaheim, CA 92806
Legal Description: N TR 1353 BLK LOT 89
APN: 26826406
CITY OF ANAHEIM
BUILDING DIVISIO%
200 S. ANAHEIM'BL .
(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 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.
lC�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.
Name of Agent:
Policy No.: 9255425 Expiration Date: 6!8/2023
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 1 should become subject to the workers compensation provisions of Section 3700 of the
Labor Code, l shall fort th comply with those provisions.
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Signature of t9bant 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 d my license is in full force and effect.
Contractor Ignatu
NUMBER EXPIRATION DATE LICENSE TYPE (S)
1034462 02/28/2025 C46
Z Z3 �
Date