920 S CLAY STPermit Types
BLD ELE MEC PLM
X
Permit Number., BLD2023-01597
Issued: 04/05/2023
www.anaheim.net/building
(714)765-0626
Quarter Section: 114
Site Address: 920 S CLAY ST, ANAHEIM, CA 92806
Legal Description: N TR 6809 BLK LOT 164
APN:25312402
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
1714) 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 pedury one of the following declarations:
I have and will maintain a certificate of consent to selfansure 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. ACE AMERICAN INSURANCE COMPANY Policy No.: WLRC50668150 Expiration Date: 3/1/2024
Name of Agent Phone No.:
_ I certify that in erforeance 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 pensation laws of California, and agree that, if I should become subject to the workers compensation provisions of Section 3700 of the
Labor e I shall fo oo ty with those provisions.
(4
Signature of Applicant Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
I hereby affirm under penally 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 CONTRA OR'S DECLARATION:
I hereby affirm u the penalty of ury that 1 am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions de, an my ficen is in fu rce and effect.
I 4fc,*
Contractor Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE ISl
602331 09/30/2024 B, 012, C-2, C39, C-6, C17, C36, D34, D41, D24, C70