2528 E BETHEL DR (7)Permit Types
BLD ELE MEC PLM
X X
'Permit Number. BLD2022-05892
Issued: 02/01/2023
www.anaheim.neUbuilding
(714)7654626
Quarter Section: 124
Site Address: 2528 E BETHEL DR, Anaheim, CA 92806
Legal Description: N TR 6452 BLK LOT 5
APN:25302108
CITY OF ANAHEIM
BUILDING DIVISION _
200 S. ANAHEIM BLVD. 3
(7141 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 deciaretions:
I have and will maintain a certificate of consent to selfinsure 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 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:
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 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 comp sation laws of California, and agree that, if I should become subject to the workers compensation provisions of Section 3700 of the
Labor Code,1 II forthwith comply with those provisions.
ignati re 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 the work for which this permit Is issued
(Sec.3097.Civ.C):
Lender's Name:
Lender's Address:
LICENSED CONTRACTOR'S DECLARATION:
I he y affirm under the penalty of Perj ry that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
P s jlons Code, and my license I77::! -
Contractor
If
,�>Wv 02 6I 2
Signature I Date
NUMBER EXPIRATION DATE LICENSE TYPE (SI
750184 06/30/2024 C10, C46, C39, B