Loading...
120 S CONNIE CIR (5)Permit Types _ BLD ELE MEC PLM X Permit Number: BLD2023-01713 Issued: 04/12/2023 www.anaheim.net/building (714)765-4626 Quarter Section: 133 Site Address: 120 S CONNIE CIR, ANAHEIM, CA 92806 Legal Description: N TR 7088 BLK LOT 64 APN:26801214 WORKER'S COMPENSATION DECLARATION: CITY OF ANAHEIM 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 selfainsure 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. 1 have and will maintain workers 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. ZURICH AMERICAN INSURANCE COMPANY Policy No.: WC140631702 Expiration Date: 6/1/2023 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, if I should become subject to the worker's compensation provisions of Section 3700 of the Code, I s 1 forthwith comply with those provisions. 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 One work for which this permit is Issued (Sec.3097.Civ.C): Lenders Name: Lenders 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 license is n full force and effect. Contractor S gnature NUMBER EXPIRATION DATE LICENSE TYPE (S) 1007845 10131/2023 C39 2 Date