5465 E FULL MOON CTPermit Types
BLD ELE MEC PLM
X
Permit Number. BLD2023-01941
Issued: 04/24/2023
www.anaheim.net/building
(714)765-0626
Quarter Section: 181
CITY OF ANAHEIM
Site Address: 5465 E FULL MOON CT , ANAHEIM, CA 92807
Legal Description: N TR 16036 BLK LOT 6
APN:36359106
WORKER'S COMPENSATION DECLARATION:
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 -5153
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 workees 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. EVEREST PREMIER INSURANCE COMPANY Policy No.: RM8WC00054231 Expiration Date: 8/1/2023
Name of Agent:
Phone No.:
1 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
worker's compensation laws of California, and agree that, B I should become subject to the worker's compensation provisions of Section 3700 of the
Labor e, l shall forthwith comply with those previsions.
. A tll,?Ylzl
Sign 7
of Applicant Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
I hereby affirm under penalty of pedury 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 Pedury 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.
Con r Signature
NUMBER EXPIRATION DATE LICENSE TYPE (S)
799170 10/31/2023 C-2, S. C20, C36
Z2g2
Date