926 S TEXELLA CT (2)Permit Types
BLD ELE MEC PLM
X I X
Permit Number: BLD202245180
Issued: 11/04/2022
www.anaheim.net/building
(714)765.4626
Quarter Section: 28
Site Address: 926 S TEXELLA CT, ANAHEIM, CA 92804
Legal Description: N TR 2529 BLK LOT 15
APN:12731140
CITY OF ANAHEIM
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 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 self4nsure for worker's compensation, issued by the Director of Industrial Relations as provided for by
IM 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 workers Compensation insurance carrier and policy are: •
Cartier. OHIO SECURITY INSURANCE COMPANY Policy No.: XWS62395213 Expiration Date: 11/20/2022
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
workers compensation laws of California, and agree that, t 1 should become subject to the workers compensation provisions of Section 3700 of the
Labor Code, I shall forthwith comply with those provisions.
IVONNE MARTINEZ 11/4/2022
Signature of Applicant
Date
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.Civ.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
Professions Code, and my license Is in full force and effect.
P G S SOLAR ELECTRICAL
Contractor Signature
NUMBER
1051116
EXPIRATION DATE
03/31/2023
LICENSE TYPE (S)
B. C70
Date
11/4/2022