3223 W FAIRCREST DR (4)Permit Types
BLD ELE MEC PLM
X I X
Permit Number: BLD2022.05473
Issued: 11/30/2022
www.anaheim.net/building
(714)765-4626
Quarter Section: 6
CITY OF ANAHEIM
Site Address: 3223 W FAIRCREST DR, ANAHEIM, CA 92804
Legal Description: N TR 2839 BLK LOT 70
APN: 07943108
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 - 5153
ON
9v
WORKER'S COMPENSATION DECLARATION:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES
AND CML 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 ce0cate of consent to self -Insure for worker's compensation, issued by the Director of Industrial Relations as provided for by
RM 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. STATE COMPENSATION INSURANCE FUND Policy No.: 9286543 Expiration Date: 10/22/2023
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
workefs 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, l shall forthwith comply with those provisions.
Ryan Mckovich 11/30/2022
Signature of Applicant
Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
—I-hereby-Wrm under -penalty of•perjury that there is a construction lending -agency -for -the perrornance-of-the•work4or•which this permit Is Issued —
(Sec.3097.Civ.C):
Lenders Name:
Lenders 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 DMsion 3 of the Business and
Professions Code, and my license Is in full force and effect.
INTEGRAL ENGINEERING CONSULTANTS INC DBA CA SOLAR GROUP 11/30/2022
Contractor Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE IS
1067781 08/31/2022 C10