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6969 E SHORECREST DRPermit Types BLD ELE MEC PLM X Permit Number: BLD2023-02131 Issued: 05/02/2023 www.anaheim.net/building (714)765-0626 Quarter Section: 217 CITY OF ANAHEIM Site Address: 6969 E SHORECREST DR, ANAHEIM, CA 92807 Legal Description: N TR 8514 BLK LOT 29 APN:36513129 WORKER'S COMPENSATION DECLARATION: BUILDING DMSIDN 200 S. ANAHEIM BLVD. (7141765- 5153 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 self4nsure 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 workees 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. SAFETY NATIONAL CASUALTY CORPORATION Policy No.: SP4068090 Expiration Date: 3/1/2024 Name of Agent: Ids- J oV 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, it I should become subject to the workers compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. Signature of Applicihk 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. Contractor Signature ` Date NUMBER EXPIRATION DATE 602331 09/30/2024 LICENSE TYPE (S) S. D12, C-2, C39, C-6, C17, C36, D34, D41, D24, C70