2123 E BLANCHARD AVEPermit Types _
BLD ELE MEC PLM
X
Permit Number: BLD2022-06047
Issued: 12/27/2022
www.anaheim.net/building
(714)765-4626
Quarter Section: 112
CITY OF ANAHEIM
Site Address: 2123 E BLANCHARD AVE, ANAHEIM, CA 92806
Legal Description: N TR 1635 BLK LOT 33
APN: 08333301
BUILDING DMSION
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 ATTORNEYS FEES.
1 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.
leC 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 carrier and policy are:
Cartier. AMERICAN ZURICH INSURANCE COMPANY Policy No.: WC614287601 Expiration Date: 10/1/2023
Name of Agent: Phone No.:
I certify that in the performance of thawylk for which this permit is issued, I shall not employ any person in any manner so as to become subject to the
/compensation laws �o CV. S'Mia, and agree that, if I should become subject to the worker's compensation provisions of Section 3700 of the
bor de, I shall forOtwJtKcd pl with those provisions.
. 12% 2� 2 Z --
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):
Lender's Name:
Lender's Address:
LICENSED C��QNTRACTOR'S DECLARATION:
1 hereby af8rrrfun er penalty of Perjury th�t nlicensed under pmvlsions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Profess) ode, and my license is in fulMrce°a effect.
1 Z
Date
NUMBER EXPIRATION DATE LICENSE TYPE (S)
750184 06/30/2024 C10, C46, C39, B