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1716 E SYCAMORE ST (2)Permit Types BLD ELE MEC PLM X Permit Number: BLD2022-04783 Issued: 10/07/2022 www.Anaheim.net/building (714)765-4626 Quarter Section: 102 CITY OF ANAHEIM Site Address: 1716 E SYCAMORE ST, ANAHEIM, CA 92805 Legal Description: N TR 1451 BLK LOT 18 APN:03526804 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 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. 1 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: Carrier. INSURANCE COMPANY OF THE.WEST Policy No.: WSD506527200 Expiration Date: 5/112023 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. %S2 6/��1 I 0 • � � Uzi 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. y✓ Contractor Signature NUMBER EXPIRATION DATE LICENSE TYPE (Sl 344837 06/30/2024 C39 in ') • 7_Z Date