2828 W ROME AVE (2)Permit Types
BLD ELE MEC PLM
X X
Permit Number: BLD2022-05460
Issued: 11/30/2022
www.anaheim.net/building
(714)765.4626
Quarter Section: 14
Site Address: 2828 W ROME AVE, Anaheim, CA 92804
Legal Description: N TR 2228 BLK LOT 132
APN:12624304
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(7141 765 - 5153
ON1'-k INS_F P�(
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 3700 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• risure for worker's compensation, issued by the Director of Industrial Relations as provided for by
RM 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 cerier and policy are:
Cartier: STATE COMPENSATION INSURANCE FUND Policy No.: 9286543 Expiration Date: 10/22/2023
Name of Agent: Phone No.:
1 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 forthwith comply with those provisions.
Ryan Mcrovich 11/30/2022
Signature of Applicant Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
-- I hereby affirm under penalty of perjury that -there Is•aransbu tion -lending -agency for the performance of the work for which this•permit4sdssued --. – —•. -- - –
(Sec.3097.Civ.C):
Lenders Name:
Lenders Address:
LICENSED CONTRACTOR'S DECLARATION:
I hereby affirm under the penalty of Perjury that 1 am licensed under provisions of chapter 9 (commencing with section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and affect
INTEGRAL ENGINEERING CONSULTANTS INC D13A CA SOLAR GROUP 11/30/2022
Contractor Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE (S)
1067781 08/31/2022 C10