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540 S PASEO LUCEROPermit Types BLD ELE MEC PLM X X Permit Number: BLD2023-00914 Issued: 05/01/2023 www.anaheim.net/buiiding (714)765-4626 Quarter Section: 198 Site Address: 540 S PASEO LUCEROANAHEIM, CA 92807 Legal Description: N TR 8455 BLK LOT 5 APN:36517133 CITY OF ANAHEIM BUILDING DMSION 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 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 labor Code, for the performance of the work for which this permit is issued. 1 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. NATIONAL CASUALTY COMPANY Policy No.: WCC334024A Expiration Date: 6/1/1023 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 rthwlth ly with those provisions. Signature piicant Date DECLARATION REGARDING CONSTRUCTION LENDING AGENCY: 1 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: 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, and my license d effect. Contractor nature Date NUMBER EXPIRATION DATE LICENSE TYPE (Sl 1029644 08131=23 B, C10, C46, C39