410 S BEECHTREE CT (2)Permit Types
BLD ELE MEC PLM
X I X
Permit Number: BLD2022-04650
Issued: 01/04/2023
www.anaheim.net/building
(714)76511626
Quarter Section: 225
CITY OF ANAHEIM
Site Address: 410 S BEECHTREE CT, ANAHEIM, CA 92808
Legal Description: N TR 13154 BLK LOT 20
APN:35423225
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765-5153
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 selfoinsure 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.
UY I 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 workers Compensation insurance carrier and policy are:
Carrier: AMERICAN ZURICH INSURANCE COMPANY Policy No.: WC614287601 Expiretion Date:01 /1/2023
Name of Agent:
Phone No.:
- In 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 workers compensation provisions of Section 3700 of the
Labor Code, I;khall forthwith comply wi those provisions.
XW -A -
Signature of App icant 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):
Lenders Name:
Lenders Address:
LICENSED CONTRACTOR'S DECLARATION:
I hereby a under the penalty of Perjury am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professe,
io s C and my license is Inful o end effect.
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Cont or Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE (S)
750184 06/30/2024 C10, C46, C39, B