755 S EAST STPermit Types
BLD ELE MEC PLM
X
Permit Number: BLD2022-05673
Issued: 12/01/2022
www.anaheim.neUbuilding
(714)765.4626
Quarter Section: 92
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 - 5153
Site Address: 755 N EAST ST 101, ANAHEIM, CA 92805
Legal Description: N TR 13916 BLK LOT 1 UN 4 TRACT 13916, LOT 1 OF PR
APN: 93014464
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
SA 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: SECURITY NATIONAL INSURANCE COMPANY Policy No.: SWC1377162 Expiration Date: 3/2312023
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, if I should become subject to the workers compensation provisions of Section 3700 of the
Labor Code, I shall forthwith comply with those provisions.
Steven A Ortiz 12/1/2022
Signature of Applicant Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
I hereby affirm.under-penalty-ofpedury4fmat4here-ls•a•construction lending agency for the performance -of -the work-for-whW4.Ws-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 end effect.
ECO -TECH ELECTRICAL SERVICES INC
Contractor Signature
NUMBER
900705
EXPIRATION DATE
03/31/2024
LICENSE TYPE (SI
C10
Date
12/1/2022