750 S STARVIEW CT (5)Permit Types .. .
BLD ELE MEC FLM
X X
Permit Number:'BLD202244995
Issued: 11/28/2022
www.anaheim.net/buiiding
(714)7654626
Quarter Section: 226
Sift Address: 750 S STARVIEW CT, ANAHEIM, CA 92808
Legal Description: N TR 13155 BLK LOT 30
APN:35426219
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 - 5153
100
FV
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 seltdnsure for worker's compensation, issued by the Director of Industrial Relations as provided for by
CF Section 3700 of the Labor Code, for the performance of the work for which this permit Is issued.
1 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: AMERISURE MUTUAL INSURANCE COMPANY Policy No.: WC21114540302 Expiration Date: 4/1/2023
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 I should become subject to the worker's compensation provisions of Section 3700 of the
Labor Code, I shall forthwith comply with those provisions.
Clinton Fallen 11/18/2022
Signature of Applicant Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
•I -hereby affirm -under -penalty -of perjury that there Ise construction lending agency tor.the performance of the-worl -for-which this permit is Issued
(Sec.3097.Civ.C):
Lenders Name:
Lenders 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.
TITAN SOLAR POWER CA INC 1128/2022
Contractor Signature ' Date
NUMBER EXPIRATION DATE LICENSE TYPE (Si
1062072 01131/2024 C46, CIO