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4321 E TERRA VISTA LNPermit Types BLD I ELE I MEC PLM X I X Permit Number: B02022-05596 Issued: 12/23/2022 www.anahejm.net/building (714)765-4626 Quarter Section: 163 CITY OF ANAHEIM Site Address: 4321 E TERRA VISTA LN, ANAHEIM, CA 92807 Legal Description: N TR 10474 BLK LOT 20 APN:36169120 BUILDING DPASION 200 S. ANAHEIM BLVD. (7141765.5153 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: 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 worker's Compensation insurance carrier and policy are: Cartier. STARR INDEMNITY &amps LIABILITY COMPANY Policy No.: 1000005080 Expiration Date: 7(jW023 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 worker's 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, l shall forthwith comply with those provisions. Signature pllcant a123�Z2 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: 1 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. Co ig re NUMBER EXPIRATION DATE LICENSE TYPE (S1 976336 09/30/2024 C10, C46 Date