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1019-1023 E RAYMOND WAYPermit Types BLD ELE MEC PLM X Permit Number: BLD2022-04502 Issued: 09/21/2022 www.anaheim.neUbuilding (714)765-4626 Quarter Section: 80 CITY OF ANAHEIM BUILDING DMSION 200 S. ANAHEIM BLVD. (7141765- 5153 Site Address: 1019-1023 E RAYMOND WAY, ANAHEIM, CA 92801 Legal Description: S TWP 3 RGE 10 SEC 34 SEC 34 T 3 R 10 POR SEI/4 APN: 26902104 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. 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: Carrier: INSURANCE COMPANY OF THE WEST Policy No.: WSD506452000 Expiration Date: 3/1/2023 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 or Code, I shall forthwith comply with those provisions. Q 0 Signature of Applicant L 9 APp 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: 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 Co e, and my license is In full force and effect. Contrac or ignature NUMBER EXPIRATION DATE LICENSE TYPE (S1 959243 03/31/2023 C39, C39 C,I2,I(Z"Z' Date