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2435 W BALL RD (5)Permit Types BLD ELE MEC PLM X Permit Number: BLD2023.01569 Issued: 04/04/2023 www.anaheim.neUbuilding (714)765-4626 Quarter Section: 28 CITY OF ANAHEIM Site Address: 2435 W BALL RD 101-103, ANAHEIM, CA 92804 Legal Description: N TR 3091 BLK LOT 1 APN:12729316 WORKER'S COMPENSATION DECLARATION: BUILDING DIVISION 200 S. ANAHEIM BLVD. (714) 765 - 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 ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OR THE LABOR CODE. INTEREST, AND ATTORNEY'S FEES. I hereby affirm under penalty of perjury one of the following declarations: I have and will maintain a certificate of consent to selfminsure for worker's compensation, issued by the Director of Industrial Relations as provided for by n J� Section 3700 of the tabor Code, for the performance of the work for which this permit is Issued. I have and will maintain worker's compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My worker's Compensation insurance carrier and policy are: Cartier. CAROLINA CASUALTY INSURANCE COMPANY Policy No.: BNUWC0166962 Expiration Date: 111012024 Name of Agent Phone No.: I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the work is compensation laws of California, and agree that, If I should become subject to the worker's compensation provisions of Section 3700 of the La r Code, I shall forthwith comply with those provisions. -4 v 2 -C) F$ plicant 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 Cod , and my license is In full force and effect. y z1V) - Copf ctor Si a re NUMBER EXPIRATION DATE LICENSE TYPE ISl 898367 06/30/2023 C39, C39, C43, C43 Date