5455 E FULL MOON CT (4)Permit Types
BLD ELE MEC PLM
X X
Permit Number: BLD2022-05175
Issued: 02/17/2023
www.anaheim.net/building
(714)765-4626
Quarter Section: 181
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 766 - 5153
Site Address: 5455 E FULL MOON CT , ANAHEIM, CA 92807
Legal Description: N TR 16036 BLK LOT 5
APN:36359105
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.
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: NATIONAL CASUALTY COMPANY Policy No.: WCC334024A Expiration Date: 6/1/2023
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 became 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.
Sam 2/20/2023
Signature of _plioant Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
I hereby affirm under penally of perjury that there is a construction lending agency for the performance of the work for which this permit is issued
(Sec.3097.Ctv.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 or the Business and
Professlons Code, and my 6oense Is in full force and effect.
- /,�aa40'W-4'
(Contrail ignature)
NUMBER EXPIRATION DATE LICENSE TYPE (S)
1029644 08/31/2023 8, C10, C46, C39
2/20/2023
Date