3639 W STADCO DRPermit Types
BLD ELE MEC PLM
X X
Permit Number: BLD2023-01399
Issued: 04/18/2023
Www.anaheim.net/building
(714)765-4626
Quarter Section: 3
Site Address: 3639 W STADCO DR, ANAHEIM, CA 92804
Legal Description: N TR 3501 BLK LOT 5
APN: 13427205
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(7141765.5153
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 self -insure 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 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 carder and policy are:
Cartier. AMERICAN ZURICH INSURANCE COMPANY Policy No.: WC614287601 Expiration Date: 10/1/2023
Name of Agent: Phone No.:
1 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
workef
ensetion laws of California, and agree that, if I should become subject to the worker's compensation provisions of Section 3700 of the
a Laborshall forthwith comply with those provisions.
Signature of AppIcant 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:
CONTRACTOR'S DECLARATION:
affirm under the penalty of Pe jury that 1 am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Code, and my license is in full tond effect.
10 __Gl
Cc fitrador Signature
NUMBER EXPIRATION DATE LICENSE TYPE (S)
750184 06/30/2024 C10, C46, C39, 6