1219 W GORDON PLPermit Types
BLD I ELE I MEC PLM
X I X
Permit Number: BLD2022-04651
Issued: 12/05/2022
www.anaheim.net/building
(714)765-0626
Quarter Section: 62
Site Address: 1219 W GORDON PL, ANAHEIM, CA 92801
Legal Description: N TR 4156 BLK LOT 20
APN: 03448231
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:
I have and will maintain a certificate of consent to selfminsure 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.
1 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:
Cartier. AMERICAN ZURICH INSURANCE COMPANY Policy No.: WC614287601 Expiration Date: 10/1/2023
Name of Agent:
Phone No.:
1 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 1 should become subject to the worker's compensation provisions of Section 3700 of the
Labor Code, I s orthwith comply with those provisions.
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S nature 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):
Lenders Name:
Lender's Address:
LICENSED CONTRACTOR'S DECLARATION:
h reby 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
OSSFesslons
Code, C nd my li nse is In full force and effect.
�Z S 22
Contractor ignature Date
NUMBER EXPIRATION DATE LICENSE TYPE (Sl
750184 06/30/2024 C10, C46, C39, B