222 S HARBOR BLVD (47)Permit Types
BLD ELE MEC PLM
X
Permit Number: BLD2022-06103
Issued: 03/28/2023 '
www.6naheim.net/building
(714)765-4626
Quarter Section: 72
Site Address: 222 S HARBOR BLVD, ANAHEIM, CA 92805
Legal Description: P BK 194 PG 22 PAR 1
APN:03619128
CITY OF ANAHEIM
BUILDING DIVISION
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 ATTORNEY'S FEES.
I hereby affirm under penalty of perjury one of the following declarations:
Q
1 �ve and will maintain a certificate of consent to self4nsure for worker's compensation, Issued by the Director of Industrial Relations as provided for by
action 3700 of the Labor Code, for the performance of the work for which this permit is issued.
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
permit is Issued. My workers Compensation insurance carrier and policy are:
Cartier. ZURICH AMERICAN INSURANCE COMPANY Policy No.: WC38040700 Expiration Date: 11112024
Name of Agent: Phone No.:
hat 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
compensation laws of rmia, and agree that, if 1 should become subject to the workers compensation provisions of Section 3700 of the
ide. I shall forthwl comply with those provisions.
24-S-(t-8.2'�ate
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 CONTRA TOR'S DECLARATION:
I hereby affirm under III penalty of Perjury that I am Ileepsed under pwvlsions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions Code n_ license is In full force�n effect.
NUMBER EXPIRATION DATE LICENSE TYPE is)
831964 02/29/2024 B. C33, C-9, C17, C23, C-2