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1734 S HEATHER LNPermit Types BLD ELE MEC PLM X Permit Number. BLD2023-02479 Issued: 05/19/2023 www.anaheim.net/building (714)765.4626 Quarter Section: 66 Site Address: 1734 S HEATHER LN, Anaheim, CA 92802 Legal Description: N TR 2180 BLK LOT 39 APN: 12942403 WORKER'S COMPENSATION DECLARATION: CITY OF ANAHEIM 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 ATTORNEYS FEES. 1 hereby affirm under penalty of perjury one of the following declarations: I have and will maintain a certificate of consent to selfinsure for workers 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 workers compensation insurance, as required by Section 3700 of the tabor Code, for the performance of the work for which this permit is Issued. My workers Compensation insurance carrier and policy are: Carrier. STATE COMPENSATION INSURANCE FUND Policy No.: 1949902 Expiration Date: 1211/2023 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 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 comp th those provisions. Signa tu Ap 1lcant 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.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 Professions Cods, *d my license Is in full forse and effect EXPIRATION DATE 956843 01/31/2025 C39 Date