6075 E MONTEFINO LNPermit Types
BLD ELE MEC PLM
X X
Permit Number: OLD2022-04771
Issued: 11/03/2022
www.anaheim.net/building
(714)765-0626
Quarter Section: 193
M ifK91S_1zL1;141�4 1
Site Address: 6075 E MONTEFINO LN, ANAHEIM, CA 92807
Legal Description: N TR 10967 BLK LOT 8
APN:08567243
BUILDING DIVISION
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 ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED
FOR IN SECTION 3706 OR THE LABOR CODE. INTEREST, AND ATTORNEYS 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 workers 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.
I have and will maintain workers compensation insurance, as required by Section 3700 of the labor Code, for the performance of the work for which
this permit Is Issued. My workers Compensation insurance carrier and policy are:
Cartier. SIRIUS AMERICA INSURANCE COMPANY Policy No.:CW 90523 Expiration Date: 211412023
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
workers 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 forth_10 _comply with those provisions.
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 penally of Perjury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Pro4ssions Code, and my license Is in full force and effect.
Date
NUMBER EXPIRATION DATE LICENSE TYPE (S)
929362 03/31/2023