294 S LEANDRO ST (3)Permit Types
BLD ELE MEC PLM
.X I X
Permit Number: BLD2022-04932
Issued: 10/18/2022
www.anaheim.net/building
(714)765.4626
Quarter Section: 192
Site Address: 294 S LEANDRO ST, ANAHEIM, CA 92807
Legal Description: N TR 8679 BLK LOT 3
APN: 36319245
CITY OF ANAHEIM
BUILDING DMSION
200 S. ANAHEIM BLVD.
(714) 765 -5153
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 ($700,000), 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:
1 have and will maintain a certificate of consent to selfwlnsure for worker's compensation, issued by the Director of Industrial Relations as provided for by
LM 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. UNITED WISCONSIN INSURANCE COMPANY Policy No.: WC518002UMSZ Expiration Date: 6/1/2023
Name of Agent: Phare No.:
I certify that in the performance of the work for which this permit is issued, l 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 workefs compensation provisions of Section 3700 of the
Labor Code, I shall forthwith comply with those provisions.
Logan Mills 10/18/2022
Signature of Applicant Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
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:
Lender's Address:
LICENSED CONTRACTOR'S DECLARATION:
I hereby affirm under the penalty of Perjury that 1 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.
SMART SOLAR DESIGN CONSTRUCTION LLC
Contractor Signature
NUMBER
1016878
EXPIRATION DATE
08/31/2024
LICENSE TYPE (SI
8
Date
10/18/2022