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410 S TORREY PINES CIRPermit Types BLD ELE MEC PLM X X Annit Number: BLD2023-00420 Issued: 01/26/2023 www.anaheim.net/building (714)765-4626 Quarter Section: 180 CITY OF ANAHEIM Site Address: 410 S TORREY PINES CIR, ANAHEIM, CA 92807 Legal Description: N TR 7566 BLK LOT 16 APN: 36307116 BUILDING DIVISION 200 S. ANAHEIM BLVD. ew (7141 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. I have and will maintain worker's compensation insurance, as required by Section 3700 of the tabor Code. for the performance of the work for which this permit is issued. My worker's Compensation insurance carrier and policy are: Cartier. EVEREST PREMIER INSURANCE COMPANY Policy No.: 7600023389221 Expiration Date: 611SQ023 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, it I should become subject to the worker's compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. P�1 7.6�ZoL3 Signature of PAplicant, Data 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: 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 in full force and effect. Contractor Sign re NUMBER EXPIRATION DATE LICENSE TYPE IS 1077027 10/31/2023 01/'L( / 74 12) Date