331 S ANISE ST (4)Permit Types
BLD ELE MEC PLM
X I X
Permit Number. OLD2023-02279
Issued: 05/10/2023
wwmanaheim.net/buiiding
(714)765-0626
Quarter Section: 214
Site Address: 331 S ANISE ST, ANAHEIM, CA 92808
Legal Description: N TR 10981 BLK LOT 66
APN: 35412408
WORKER'S COMPENSATION DECLARATION:
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(7141765.5153
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES
AND CML 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 at= 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, (or 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:
Cartier. AMERICAN ZURICH INSURANCE COMPANY Policy No.: EWS107458505 EVIration Date:1013112023
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 compensa' n laws of California, and agree that, if I should become subject to the worker's compensation provisions of Section 3700 of the
r e, I aha f with with those provisions. sho/ .23
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:
1 hereby affirm under the Ity of Perjury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions a and lIcons e s in li force and e
Contractor Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE (S)
888104 12/31/2024 C36, C46, B. C10, C39