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3370 E LA PALMA AVE (5)Permit Types PBLD ELE MEC PLM X Permit Number: OLD2022-04677 Issued: 10/03/2022 www.anaheim.nef/building (714)765.4626 Quarter Section: 145 CITY OF ANAHEIM BUILDING DIVISION 200 S. ANAHEIM BLVD. (714) 765 - 5153 Site Address: 3370 E LA PALMA AVE, ANAHEIM, CA 92806 Legal Description: A TR ORANGE GROVE ACRES BLK LOT 6 ORANGE GROVE ACR APN: 34512102 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 ATTORNEYPS 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. O/ 1 have and will maintain workers compensation Insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which (C this permit is issued. My workers Compensation insurance carrier and policy are: Cartier. Policy No.: GLSISTC002067722 Expiration Date: 5/27/2023 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 compen tion laws of California, and agree that, 01 should become subject to the workers compensation provisions of Section 3700 of the Labor Code, all forthwith comply with those provisions. 1 1/1/0__?%2 7 SignatureAp lica Date r 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: Lenders Address: LICENSED CONTRACTOR'S DECLARATION: 1 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 m 4'oense is in full force and effect. r'0 a 2 Contrac� or Sig atu Date NUMBER EXPIRATION DATE LICENSE TYPE ISl 1057026 08/31/2023 C10