2521 W CONLEY AVEPermit Types
BLD ELE MEC PLM
X X
Permit Numbdr BLD2023„�237
Issued: 02/08/2023
www.anaheim.net/building
(714)765.4626
Quarter Section: 28
Site Address: 2521 W CONLEY AVE, ANAHEIM, CA 92804
Legal Description: N TR 2062 BLK LOT 4
APN: 12718161
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 - 5153
f.4
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.
1 hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certificate of consent to self4nsure for workers 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 carder and policy are:
Carrier: AMERICAN ZURICH INSURANCE COMPANY Policy No.: EWS107458505 Expiration Date:01 /31/2023
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 compensation laws of California, and agree that, if I should become subject to the workers compensation provisions of Section 3700 of the
kebetCode, I with those provisions.
2
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):
Lenders Name:
Lenders Address:
LICENSED CONTRACTOR'S DECLARATION:
I hereby affirm under the penalty of Perjury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
ProfeslI once
2 2�
Cont cto S' nature Date
NUMBER EXPIRATION DATE LICENSE TYPE IS)
688104 12/3112024 C46, B, C10, C39, C36