940 S OAK MEADOWS WAY (2)Permit Types
BLD ELE MEC I PLM
X X X X
Permit Number: BLD2022-05098
Issued: 10/26/2022
www.anaheim.net/building
(714)765-4626
Quarter Section: 226
CITY OF ANAHEIM
Site Address: 940 S OAK MEADOWS WAY, ANAHEIM, CA 92808
Legal Description: N TR 15126 BLK LOT 5
APN:51406142
WORKER'S COMPENSATION DECLARATION:
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 - 5153
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.
1 hereby affirm under penalty of pedury 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: PREFERRED PROFESSIONAL INSURANCE COMPANY Policy No.: ON1226101 Expiration Date: 12/28/2022
Name of Agent: Phone No.:
I certify that in the performance of the work for which this permit is issued, l 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 workers compensation provisions of Section 3700 of the
LB&r Code, I shall forthwith comply with those provisions.
Sig t 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:
Lenders 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, d my license is in full force and effect.
If lKirz-1d,
, /Z,)/ W —
Co rec r Signature W - e7
NUMBER EXPIRATION DATE LICENSE TYPE (SI
1032562 11/30/2023
Date