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2470 S LOOM CTPermit Types BLD ELE MEC PLM X Permit Number: BLD202340087 Issued: 01/11/2023 www.anaheim.net/building (714)765-4626 Quarter Section: 109 CITY OF ANAHEIM BUILDING DIVISION 200 S. ANAHEIM BLVD. (714) 765.5153 Site Address: 2470 S LOOM CT, ANAHEIM, CA 92802 Legal Description: N TR 17920 BLK LOT 1 UN 85 LOT 1 OF TRACT 17920 OF APN:93206501 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 self4nsure for worker's compensation, issued by the Director of Industrial Relations as provided for by GA Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 1 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. SIRIUS AMERICA INSURANCE COMPANY Policy No.: WC1665303 Expiration Date: 012023 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, if I should become subject to the worker's compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. Gerardo Alcantara 1/11/2023 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): Lenders Name: Lender's 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 Code, and my license is in full force and effect. CYSERTECH ELECTRIC Contractor Signature NUMBER EXPIRATION DATE LICENSE TYPE (S) 1016343 07/31/2024 C10 Date 1/11/2023