146 S VISTA GRANDE (7)Permit Types
BLD I ELE I MEC PLM
X I X
Permit Number. OLD2022.05140
Issued: 12/02/2022
www.anaheim.neUbuilding
(714)765.4626
Quarter Section: 179
CN- AJJs--. 41 . n
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Legal Descrlptlon: N TR 14641 BLK LOT 4
APN:36322116
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANANEIt# BLVD.
(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 CML 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:
1 have and will maintain a certificate of consent to self4nsure for workers compensation, issued by the Director of Industrial Relations as provided for by
NP Section 3700 of the Labor Code, for the Performance of the work for which this permit is issued.
1 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:
Carrier. TRAVELERS PROPERTY CASUALTY COMPANY OF AM RIGA Policy No.: U_BOT676 9999 Expiration Date: 1/11/2023
Name of Agent: - -
Phone No.: -
I certify that in the performance of the work for which this permit Is issued, I shall not employ an
workers compensation laws of California`and agree that, if I should become subject to the worker'srecomp nation pro si as o Dewe ofct to-ttie
Labor Code, I shall forthwith complyPe Provisions of Sectio -n-1700 of the
with those provisions.
Nickolas Phillips
Signature of Applicant -
1211/2022
Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY -
6 -hereby -affirm under -penalty -0f pe4uq0AaMhe*4sa.co �emaerh� Ace -of -the *fir -which thi
(Sec.3097.Civ.C): &"nPAW- " e
Lenders Name:
Lenders 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.-
POWUR PBC WHICH WILL DO BUSINESS IN CALIFORNIA AS POWUR HOME
Contractor Signature
NUMBER EXPIRATION DATE LICENSE TYPE fSl
1060243 11/3012023 CIO, B
12/2/2022
Date