376 S OLD BRIDGE RDPermit Types
BLD ELE MEC PLM
X I X
Permit Number: BLD2022-056.35
Issued: 01/30/2023
www.anaheim.net/building
(714)765-0626
Quarter Section: 203
CITY OF ANAHEIM
Site Address: 376 S OLD BRIDGE RD, ANAHEIM, CA 92808
Legal Description: N TR 15927 BLK LOT 6
APN:35634122
BUILDING DIVISION
206`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.
1 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 workers compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which
A A this permit is issued. My workers Compensation insurance carrier and policy are:
Cartier. AMERICAN ZURICH INSURANCE COMPANY Policy No.: EWS107458505 Expiration Date: 10/31/2023
Name of Agent: Phone No.:
I 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 we of California, and agree that, if I should become subject to the worker's compensation provisions of Section 3700 of the
I shall fo' mply with a provisions.
-Signature -of Applicant -,Fate
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 CONTRACTOR'S DECLARATION:
1 hereby af8nnpnder a penalty oJ}Perjury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions ode, d my liceg is in bdilorce anieffect.
NUMBER EXPIRATION DATE
888104 12/31/2024
LICENSE TYPE (S)
C46, B. C10, C39, C36
(Ac> _
Date 'r