1000 N ROANNE PLPermit Types
BLD ELE MEC PLM
X I X
Permit Number: BLD2023-01244
Issued: 04/14/2023
www.anaheim.net/building
(714)765-0626
Quarter Section: 25
Site Address: 1000 N ROANNE PL, ANAHEIM, CA 92801
Legal Descrlptlon: N TR 2326 BLK LOT 49
APN: 07139228
CITY OF ANAHEIM
BUILDING DMSION
200 S. ANAHEIM BLVD.
1714) 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 selfinsure for worker's compensation, issued by the Directoi 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 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: STARNET INSURANCE COMPANY Policy No.: ONUWC0159546 Expiration Date: 4/812024
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
worker's compensation laws of California, and agree that, if I should become subject to the worker's compensation provisions of Section 3700 of the
rauLabor Code, I shall forthwith comply with those provisions.
0 1 po iv
ign f Appii ant 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:
Lender's Address:
LICENSED CONTRACTOR'S DECLARATION:
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
ft and my license is in full force and effect.
L4 I y a/J
'Date
NUMBER EXPIRATION DATE LICENSE TYPE (S)
1023627 02/28/2025 C10, B