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2950 W ROME AVEPermit Types BLD ELE MEC X X X Permit Number. BLD2022-05742 Issued: 08/19/2022 www.anaheim.neUbuilding (714)7654626 Quarter Section: 14 Site Address: 2950 W ROME AVE, ANAHEIM, CA 92804 Legal Description: N TR 2228 BILK LOT 5 APN:12625206 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. 1 hereby affirm under penalty of perjury one of the following declarations: u I have and will maintain a certificate of consent to self4nsure 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: Cartier: Policy No.: Expiration Date: 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 workers 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 shall forthwith comply with those provisions. Signature of Applicant N- / C9 2 ? 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: Lender's 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 is full force and effect. Contractor Signature NUMBER EXPIRATION DATE LICENSE TYPE IS 1018333 09!30/2022 (Z/©�-/ ,-0Z- Date