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1818 E TURIN AVEPermit Types BLD ELE ME4m-- X Permit Number: BLD2023-00405 Issued: 01/25/2023 www.anaheim.net/building (714)765-0626 Quarter Section: 105 Site Address: 1818 E TURIN AVE, ANAHEIM, CA 92805 Legal Description: N TR 6409 BLK LOT 86 APN: 23405407 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 ATTORNEYS FEES. I hereby affirm under penalty of perjury one of the following declarations: I have and will maintain a certificate of consent to selfansure for workers compensation, issued by the Director of Industrial Relations as provided for by t7 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: EVEREST PREMIER INSURANCE COMPANY Policy No.: 7600019997231 Expiration Date: 1/9/2024 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 compensation laws of California, and agree that, If I should become subject to the workers compensation provisions of Section 3700 of the Labor C e,1 shall forthwith comply with those provisions. ©//-Y) z Signature of Appli an _ Date DECLARATION REGARDING CONSTRUCTION LENDING AGENCY: 1 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 Cade d my license is in full force and effect. `Contractor_Sigature Date } NUMBER EXPIRATION DATE LICENSE TYPE (S) 974840 07/3112024