1015 S WINDY RIDGE CTPermit Types
BLD ELE MEC PLM
X
Permit Number: BLD2023-02276
Issued: 05/15/2023
www.anaheim.net/building
(714)765-4626
Quarter Section: 216
CITY OF ANAHEIM
Site Address: 1015 S WINDY RIDGE CT, ANAHEIM, CA 92808
Legal Description: N TR 12701 BLK LOT 41
APN:36552220
BUILDING DIVISION
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.
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certificate of consent to seff4nsure for worker's compensation, issued by the Director of Industrial Relations as provided for by
ML Semon 3700 of the Labor 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 worker's Compensation insurance carrier and policy are:
Cartier. DEPARTMENT OF INDUSTRIAL RELATIONS Policy No.: INT45030307 Expiration Date: 1/1/2024
Name of Agent: Phone No.:
I certify that in the performance of the work for which this permit is issued, l shall not employ any person in any manner so as to become subject to the
worker's compensation laws of California, and agree that, it I should become subject to the workers compensation provisions of Section 3700 of the
Labor Code, I shall forthwith comply with those provisions.
Michael Legunas 5/15/2023
Signature of Applicant 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 Code, and my license is in full force and effect.
ALBD ELECTRIC AND CABLE 5/15/2023
Contractor Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE (SI
843942 06/30/2024 C10
Permit Types
BLD ELE MEC PLM
X
Permit Number: BLD2023-02276
Issued:
www.anaheim.net/building
(714)765-0626
Quarter Section: 216
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 - 5153
Site Address: 1015 S WINDY RIDGE CT, ANAHEIM, CA 92808
Legal Description: N TR 12701 BLK LOT 41
APN:36552220 `
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 pedury 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 tabor Code, for the performance of the work for which this permit Is Issued.
ML
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 worker's Compensation insurance carrier and policy are:
Cartier. DEPARTMENT OF INDUSTRIAL RELATIONS Policy No.: INT45030307 Expiration Date: 6/30/2022
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'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, I shall forthwith comply with those provisions.
Michael Lagunas 5/12/2023
Signature of Applicant 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 1 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.
ALBD ELECTRIC AND CABLE 5/12/2023
Contractor Signature - - Date
NUMBER EXPIRATION DATE LICENSE TYPE (Sl
843942 06/30/2024 C10