2164 W FALMOUTH AVE (2)Permit Types
ELEMEC
BLD PLM
X
Permit Number: BLD2022-04493
Issued: 09/21/2022
www.anaheim.net/building
(714)765-4626
Quarter Section: 37
CITY OF ANAHEIM
Site Address: 2164 W FALMOUTH AVE, ANAHEIM, CA 92801
Legal Description: N TR 2093 BLK LOT 155
APN: 07241514
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(7141 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 ATTORNEYS FEES.
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certificate of consent to selfainsure for worker's compensation, Issued by the Director of Industrial Relations as provided for by
CH Section 3700 of the Labor Code, for the performance of the work for which this permit is Issued.
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. ACCREDITED SURETY AND CASUALTY COMPANY INC Policy No.:1ATCA16000219 Expiration Date: 91V2023
Name of Agent: Phone No.:
I cerldy 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 Secion 3700 of the
Labor Code, I shall forthwith comply with those provisions.
Chad Holder 9/2112022
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:
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 and
Professions Code, and my license is In full force and effect.
ION ELECTRIC INC
Contractor Signature
NUMBER
951482
EXPIRATION DATE
08/31/2022
1114q-4211- - 1 -
C10
Date
9/21/2022