1005 S SUNSTREAM LN (3)Permit Types
BLD ELE MEC PLM
X X
Permit Number. BLD202341400
Issued: 05/17/2023
www.anaheim.netlbuilding
(714)765-4626
Quarter Section: 221
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(711411765-51153
Site Address: 1005 S SUNSTREAM LN, ANAHEIM, CA 92808
Legal Description: N TR 13515 BLK LOT 5 TRACT 13515 LOT 5 AND POR LOT
APN: 35433153
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 setfdnsure for workers compensation, Issued by the Director of Industrial Relations as provided for by
n Section 3700 of the Labor Code, for the performance of the work for which this permit is issued.
1 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. AMERICAN ZURICH INSURANCE COMPANY Policy No.: WC614287601 Expiration Date: 101112023
Name of Agent:. Phone No.:
1 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 laws of California, and agree that, If I should become subject to the workers compensation provisions of Section 3700 of the
`Labor Code,1 shall forthwith comply with those provisions.
I
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):
Lenders Name:
Lenders Address:
LICENSED CONTRACTOR'S DECLARATION:
1 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
Profs s e, and my license is in full force an effect.
Con for Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE 1S1
750184 06/30/2024 C10, C46, C39, 8