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1032 S MILES CTPermit Types BLD ELE MEC PLM X Permit Number. BLD2023-00022 Issued: 03/10/2023 www.anaheim.nel/building (714)765-0626 Quarter Section: 215 CITY OF ANAHEIM o�.h br fit BUILDING DMSION 200 S. ANAHEIM BLVD. (7141765-5153 Site Address: 1032 S MILES CT, ANAHEIM, CA 92808 Legal Description: N TR 12687 BLK LOT 114 APN: 35654424 `. 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 Section 3700 of the tabor 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. ACE AMERICAN INSURANCE COMPANY Policy No.: WLRC50684349 Expiration Date: 7/112023 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, l shall forthwith comply with those provisions. 3 ature 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: 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 Profess ns Code, and my license is in full force and effect. CoTtrjdctor Signature NUMBER EXPIRATION DATE LICENSE TYPE ISl 762828 05/31/2023 B. C33 I -i Date rrr.%**U 7