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1211 N EARL CIRPermit Types BLD ELE MEC PLM X Permit Number: BLD2022-04515 Issued: 11/01/2022 www.anaheim.net/building (714)7654626 Quarter Section: 111 CITY OF ANAHEIM BUILDING DIVISION 200 S. ANAHEIM BLVD. (7141765-5153 Site Address: 1211 N EARL CIR, ANAHEIM, CA 92806 Legal Description: N TR 1353 SLK LOT 7 ' APN: 26826135 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 ($700,000), 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 selfinsure for worker's compensation, issued by the Director of Industrial Relations as provided for by MM Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 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 permit is issued. My worker's Compensation insurance carrier and policy are: Cartier. TECHNOLOGY INSURANCE COMPANY INC Policy No.: TWC4102876 Expiration Date: 4/15/2023 Name of Agent' - Phone No.: I car* 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, l shall forthwith comply with those provisions. Maggie Matthews Signature of Applicant Date 1111/2022 DECLARATION REGARDING CONSTRUCTION LENDING AGENCY: 1 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 Cade, and my license is in full force and effect BETTER EARTH ELECTRIC INC Contractor Signature NUMBER EXPIRATION DATE LICENSE TYPE (S) 1024460 03/31/2023 C70 Date 11/1/2022