6263 E VIA RIBAZO (4)Permit Types
BLD ELE MEC PLM
X X
Permit Number: BLD2022-06097
Issued: 12/30/2022
www.anaheim.nef/building
(714)765-0626
Quarter Section: 196
Site Address: 6263 E VIA RIBAZOANAHEIM, CA 92807
Legal Description: N TR 8423 BLK LOT 25
APN:35824511
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(7141765-5153
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 aitrtn under penalty of perjury one of the following declarations:
I have and will maintain a certificate of consent to self4nsum 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.
JK
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: CLEAR SPRING PROPERTY AND CASUALTY COMPANY Policy No.: CWC00207901 Expiration Date:01 /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.
Jennifer Kemme 12/30/2022
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):
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 end
Professions Code, and my license is in full force end effect.
111 ECE INC 12/30/2022
Contractor Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE (SI
1040577 06/30/2024 C46, B
Pv