1618 E VERDE CIR (2)Permit Types
BLD ELE MEC PLM
X X
Permit Number: BLD2023-02183
Issued: 05/19/2023
www.anaheim.net/building
(714)765-0626
Quarter Section: 104
Site Address: 1618 E VERDE CIR, ANAHEIM, CA 92805
Legal Description: N TR 3371 BLK LOT 81
APN:08250118
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM 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 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 selfansure for worker's compensation, issued by the Director of Industrial Relations as provided for by
EH 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 tabor Code, for the performance of the work for which
this permit is issued. My worker's Compensation insurance carrier and policy ere:
Cartier: MIDWEST EMPLOYERS CASUALTY COMPANY Policy No.: BNL WC0158304 Expiration Date: 11/1812023
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.
Erice Heron 5119/2023
Signature of Applicant
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):
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
EMPOWER ELECTRIC SOLAR
Contractor Signature
NUMBER
1057693
EXPIRATION DATE
09/30/2023
LICENSE TYPE (S)
C10
Date
5/19/2023