1230 S KINGS COURT DR (4)Permit Types
BLD ELE MEC PLM
X X
;Viirdt Numl'atff OLD2023-00279
Issued: 02/16/2023
www.anaheim.net/building
(714)765-4626
Quarter Section: 49
CITY OF ANAHEIM
Slte Address: 1230 S KINGS COURT DR, ANAHEIM, CA 92804
Legal Description: N TR 3361 BLK LOT 1
APN: 12837212
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 ATTORNEY'S FEES.
I hereby affirm under penalty of pedury one of the following declarations:
I have and will maintain a certificate of consent to selfdnsure 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 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 carrier and policy are:
Cartier. AMERICAN ZURICH INSURANCE COMPANY Policy No.: EiYS107458505 Expiration Date: 10131=3
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 compensa ' lifomie, and agree that, if I should become subject to the workers compensation provisions of Section 3700 of the
LsboW;or dq,1 all forthwith oompy wit egg provisions.
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:
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
Professions Code, andaWiLcense i an a ec .
2J
Date
NUMBER EXPI041N DATE LICENSE TYPE ISI
886104 12/31/2024 C46, B. C10, C39, C36