574 S MOTIF ST (2)Permit Types
BLD ELE MEC PLM
X
Permit Number. OL:D202245609
Issued: 11/28/2022
www.anaheim.net/building
(714)765-4626
Quarter Section: 93
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 - 5153
Site Address: 574 S MOTIF ST, Anaheim, CA 92805
Legal Description: N TR 18101 BLK LOT 8 UN HOLD LOT 8 OF TRACT 18101;
APN:03731036
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
JP 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:
Carrier. OHIO CASUALTY INSURANCE COMPANY (THE I Policy No.: XWS23592ONN Expiration Date: 1131/2023
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 comply with those provisions.
Jorge Porres 11/28/2022
Signature of Applicant Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
I hereby affirm under -penalty of-perjury-thaMhere is a construction lending agency for the performance of the-work-for-which-this-pennk4s4ssued-----
(Sec.3097.Civ.C):
Lenders Name:
Lenders Address:
LICENSED CONTRACTOR'S DECLARATION:
I hereby affirm under the penally 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.
FARADAY ELECTRIC CORP
Contractor Signature
NUMBER EXPIRATION DATE LICENSE TYPE ISl
1046805 11/30/2022 C10
Date
11/28/2022