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1175 S HIDDEN CANYON RD (3)Permit Types BLD ELE MEC PLM X Permit Number. BLD2023-00618 Issued: 02/07/2023 www.anaheim.nef/building (714)765-0626 Quarter Section: 288 CITY OF ANAHEIM BUILDING DIVISION 200 S. AMEIM BLVD. (714) 765 - 5153 Site Address: 1175 S HIDDEN CANYON RD, ANAHEIM, CA 92807 Legal Description: N TR 10998 BLK LOT 1 APN:36541101 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. MI have and will maintain workers 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.: 9077388 Expiration Date: 3/1/2023 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 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, I shall forthwith compy with those provisions. Signature of Applicant DECLARATION REGARDING CONSTRUCTION LENDING AGENCY: 2/-71Z3 Date 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: 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 Division 3 of the Business and P sions Code, and my license is in full force and effect. Contractor Signature NUMBER EXPIRATION DATE LICENSE TYPE IS) 847279 09/30/2024 B. C39 ZI -7 Date