2882 E VIRGINIA AVEPermit Types
BLD ELE MEC PLM
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Permit Number: BLD2022-06179
Issued: 12/30/2022
www.anaheim.net/building
(714)765.4626
Quarter Section: 134
Site Address: 2882 E VIRGINIA AVE, Anaheim, CA 92806
Legal Description: N TR 4182 BLK LOT 7
APN:25326315
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765.5153
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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
AS Section 3700 of the tabor 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 Labor Code, for the performance of the work for which
this permit is Issued. My workers Compensation insurance carrier and policy are:
Carrier: NORGUARD INSURANCE COMPANY Policy No.: PRWC396523 Expiration Date: 8/10/2023
Name of Agent:
Phone No.:
I certify that in the performance of the work for which this permit is issued, I shall not employ 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 worker's compensation provisions of Section 3700 of the
Labor Code, l shall forthwith comply with those provisions.
Andrew S Hanna 12/30/2022
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):
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 Code, and my license is In full force and effect.
PREMIER POWER INC
Contractor Signature
NUMBER EXPIRATION DATE LICENSE TYPE (S)
1096050 09/30/2024 C10
12/30/2022
Date
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