5550 E EDGEMAR AVEPermit Types
BLD ELE MEC PLM
X X
Permit Number: BLD2023-00974
Issued: 04/27/2023
wormanaheim.net/building
(714)765-0626
Quarter Section: 185
CITY OF ANAHEIM
Site Address: 5550 E EDGEMAR AVE, ANAHEIM, CA 92807
Legal Description: N TR 6717 BLK LOT 52
APN:35804152
WORKER'S COMPENSATION DECLARATION:
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765-5153
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.
I hereby affirm under penalty of pedury 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.
I have and will maintain worker's compensation insurance, as required by Section 3700 of the tabor Code, for the performance of the work for which
this permit is issued. My worker's Compensation insurance carrier and policy are:
Carrier. AMERICAN ZURICH INSURANCE COMPANY Policy No.: WC614287601 Expiration Date: 10/1/2023
Name of Agent: Phone No.:
I cerci y 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 worker's compensation provisions of Section 3700 of the
Labor Code, I shall foRhwlth ply with those provisions.
ftiq A NEI 3
Sibnature 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:
Lenders Address:
LICENSED CONTRACTOR'S DECLARATION:
1 p'erNy 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
es Ions Code, end my license Is in full fo and effect.
nt or Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE (S)
750184 06/30/2024 C70, C46, C39, B