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212 S ASH ST (2)Permit Types BLD ELE MEC PLM X Permit Number: BLD2023-02512 Issued: 05/22/2023 www.anaheim.net/buiiding (714)765-4626 Quarter Section: 103 Site Address: 212 S ASH ST, Anaheim, CA 92805 Legal Description: N TR 1565 BLK LOT 91 APN: 03722111 CITY OF ANAHEIM BUILDING DMSION 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 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. 1=� 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 peril is Issued. My workers Compensation insurance carrier and policy are: Carrier. STATE COMPENSATION INSURANCE FUND Policy No.: 9310590 Expiration Date: 120-812023 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 workers compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. Z 6111-11-5 Signature oft#pflbantl 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 Pedury 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. NUMBER EXPIRATION DATE LICENSE TYPE ISl 1058455 09/30/2023 B. C39 $l 11M5 Date