6411 CYMBAL ST (2)Permit Types
BLD ELE I MEC PLM
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Permit Number: AD2023-00-M
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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 selfinsure for worker's compensation, issued by the Director of Industrial Relations as provided for by
ZM 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 Labor Code, for the perfarrnance of the work for which
this permit is issued. My workers Compensation insurance carrier and policy are.
Cartier: STATE COMPENSATION INSURANCE FUND Policy No.: 9245610 Expiration Data: 2/8/2023
Name of Agent: Phone No.:
I car* 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.
Zachary Mohr
2/14/2023
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):
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
Professlons Code, and my license is in full force and effect.
SOLIRVINE LLC
2/14/2023
Contractor Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE rah
1050892 03/31/2023 C46
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