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7841 E WOODSBORO AVE (3)Permit Types _ BLD ELE MEC PLM X X Pe°Anil Number. OLD2022-05746 Issued: 02/14/2023 wwwAnaheim.net/building (714)765-4626 Quarter Section: 200 CITY OF ANAHEIM Site Address: 7841 E WOODSBORO AVE, ANAHEIM, CA 92807 Legal Description: N TR 8831 BLK LOT 104 APN:35109140 BUILDING DMSION dil 200 S. ANAHEIM BLVW4 ' ' (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 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 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: Cartier. CLEAR SPRING PROPERTY AND CASUALTY COMPANY Policy No.: CWC00872800 Expiration Date: 6/10/2023 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, d' I should become subject to the workers compensation provisions of Section 3700 of the Labor Code, I sh forthwith co se provisions. Alp N ©�`lV 1 a 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 Proles o Code, and my, is full and ct. Contractor Signature NUMBER EXPIRATION DATE LICENSE TYPE (S) 1080602 11/30/2023 0 0,3 --z Date