5389 E RURAL RIDGE CIRPermit Types
BLD ELE MEC PLM
X I X
Permit Number: BLD2023-01353
Issued: 05/02/2023
www.anaheim.net/building
(714)765.4626
Quarter Section: 181
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 - 5153
Site Address: 5389 E RURAL RIDGE CIR, ANAHEIM, CA 92807
Legal Description: N TR 7568 BLK LOT 85 TR 7568 LOT 85 AND POR OF LOT
APN:36315211
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 self -Insure 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.: EWS107458505 Expiration Date:1013112023
Name of Agent: Phone No.:
I certify that in the performance of the work for which this peril is issued, I shall not employ any person in any manner so as to become subject to the
wo efs compensation laws of California, and agree that, if I should become subject to the worker's compensation provisions of Section 3700 of the
2aL)Ior C e, I she forthwith ply with those provisions.
&-A 11?13
Signature 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 penal of Perjury that i am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professioq Code/';nd my Ij�e is in full force and effect.
Contractor Signature
NUMBER
888104
EXPIRATION DATE
12/31/2024
LICENSE TYPE IS)
C46, B. C10, C39, C36
Date