1000 E HOWELL AVEPermit Types
BLD ELE MEC PLM
X
Permit Number: BLD2023-01814
Issued: 04/18/2023
www.anaheim.netlbuilding
(714)765-0626
Quarter Section: 107
Site Address: 1000 E HOWELL AVE, ANAHEIM, CA 92805
Legal Description: P BK 205 PG 21 PAR 2
APN:08226120
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(7141765-5153
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 ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED
FOR IN SECTION 3706 OR THE LABOR CODE. INTEREST, AND ATTORNEYS FEES.
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certificate of consent to self4nsure for worker's compensation, issued by the Director of Industrial Relations as provided for by
Section 3700 of the Labor Code, for the performance of the work for which this permit Is Issued.
I have and will maintain worker's compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which
this permit Is issued. My worker's Compensation insurance carrier and policy are:
CarderAMERICANZURIg URANCECOMPANY Policy No.: WC112580204 Expiration Date: 12/31/2023
Name of Agentl U t�da Phone No.:
1' that in the performance of the work for which this permit Is issued, l shall not employ any person In any manner so as to become subject to the
wo er' compensation laws of California, and agree that, if I should become subject to the worker's compensation provisions of Section 3700 of the
Lab ode, I shall forthwith comply with those provisions.
'2
!$ignat of App 'pant 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:
Code,
NUMBER
672569
'S DECLARATION:
of Perjury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business end
e Is In full force and effect.
EXPIRATION DATE
06/30/2023
LICENSE TYPE (S)
C39, B
41423
Date