2668 E SYCAMORE STPermit Types
BLD ELE MECPLM
X X
Permit Number: BLD2023-00968
Issued: 04/12/2023
www.anaheim.net/buiiding
(714)765.4626
Quarter Section: 122
CITY OF ANAHEIM
Site Address: 2668 E SYCAMORE ST, ANAHEIM, CA 92806
Legal Description: N TR 3614 BLK LOT 19
APN:26830307
BUILDING DIVISION
200 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.
I hereby affirm under penalty of perjury one of the following dedaretions:
I have end will maintain a certificate of consent to selfansure for workers 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 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: 10/31/2023
Name of Agent: Phone No.:
I certify that in the p rfomtance 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
wprker's96mpenon laws of California, and agree that, if I should become subject to the worker's compensation provisions of Section 3700 of the
forthwith O iiply wii1 those provisions.
Of
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:
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
Professions e, a my nse is i II fo and effect.
6/ O1 �3
Co rector Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE (S)
888104 12/31/2024 C46, B, C10, C39, C36