1173 N LOTUS ST (2)Permit Types
BLD ELE MEWa-
Permit
X Number: BLD2023-00351 v
Issued: 01/24/2023
www.anaheim.net/building
(714)76511626
Quarter Section: 37
Site Address: 1173 N LOTUS ST, ANAHEIM, CA 92801
Legal Description: N TR 2093 BLK LOT 123
APN: 07241611
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 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
pec, this permit is issued. My workers Compensation insurance carrier and policy are:
Cartier. AMERICAN ZURICH INSURANCE COMPANY Policy No.: WC614287601 Expiration Date: 10/1/2023
Name of Agent:
Phone No.:
I certify 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
rkers compensation Igs of V f omia, and agree that, it I should become subject to the workers compensation provisions of Section 3700 of the
AO -Labor s, I shall f with mpfy with those provisions.
/Zer i23
Da
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
I hereby affirm under penalty of pedury 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 CONTRACTOR'S DECLARATION:
I hereby affirm ugder the penalty of Perjury that IamInsed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
dvn
Professions C96,any license is in full fpr:e grfd'effect.
l2
Dat
NUMBER EXPIRATION DATE LICENSE TYPE (S)
750184 06/30/2024 C10, C46, C39, B