370 S SILVERBROOK DR (9)Permit Types
BLD ELE MEC PLM
X X
Permit Number: BLD2022-05984
Issued: 12/19/2022
www.anaheim.netlbuilding
(714)7654626
Quarter Section: 180
CITY OF ANAHEIM
Site Address: 370 S SILVERBROOK DR, ANAHEIM, CA 92807
Legal Description: N TR 8783 BLK LOT 60
APN:36323314
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 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
this permit is issued. My workers Compensation insurance carrier and policy are:
Cartier: MID-CENTURY INSURANCE COMPANY Policy No.: A09488759 Expiration Date: 1/612023
Name of Agent. Phone No.:
Irtify that in th 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
wo ers mpen tion laws of California, and agree that, If I should become subject to the workers compensation provisions of Section 3700 of the
Le o C e 1 sh I forthwith comply with those provisions.
Si nature I Z ) I !i I 2 -?-
of
gApplicant 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:
LICENSE CO TRACTOR DECLARATION:
I hereby a re un a the penalty f Perjury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professi - Code, a my n is in full force and effect.
I -2-1 -1 I ZZ
Contractor Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE ISl
993912 06/30/2024 C54