429 S OAK GROVE CIR (2)Permit Types
BLD ELE MEC PLM
X
Permit Number: BLD2023-00023
Issued: 01/04/2023
www.anaheim.net/building
(714)765-0626
Quarter Section: 180
CITY OF ANAHEIM
Site Address: 429 S OAK GROVE CIR, ANAHEIM, CA 92807
Legal Description: N TR 7569 BLK LOT 53
APN:36309309
WORKER'S COMPENSATION DECLARATION:
BUILDING DIVISION
200 S. ANANEIM 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 perjury one of the following declarations:
I have and will maintain a certificate of consent to self4risure 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 tabor 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.: WC61428TS01 Expiration Date: 101112023
Name of Agent: Phone No.:
LLa
ertify 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
rker's w nsation laws of California, and agree that, it I should become subject to the worker's compensation provisions of Section 3700 of the
r Cod I hall forthwith comply with those provisions.
2�
na ure 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):
Lender's Name:
Lender's 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
Professio9, and my license Is in full force and effect. /
D/
Cont or Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE ISI
750184 06/30/2024 C10, C46, C39, B