2851 W TYLER AVEPermit Types
BLD ELE ME:C:T PLM
X
Permit Number. BLD2022-05321
Issued: 11/09/2022
www.anaheim.net/buiiding
(714)765-4626
Quarter Section: 12
Site Address: 2851 W TYLER AVE, ANAHEIM, CA 92801
Legal Description: N TR 2780 BLK LOT 31
APN:07049208
CITY OF ANAHEIM
BUILDING) DIVISION
200 S. ANAHEIM BLVD.
(7141765.5153
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 ATTORNEYS 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.
prr I have and will maintain worker's compensation insurance, as required by Seclion 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.: WC61428MI Expiration Date: 10/1/2023
Name of Agent:. Phone No.:
I certify that in the 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
worker's compensation laws of California, and agree that, if I should become subject to the workers compensation provisions of Section 3700 of the
Labor Code, I shall forthwith comply with those provisions.
1/ z V 2 -,L-
of Ap hcant 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:
Lenders Address:
LICENSED CONTRACTOR'S DECLARATION:
I hereby affirm under the penalty of Pedury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect. -
Contractor Signature
NUMBER EXPIRATION DATE LICENSE TYPE (Sl
750184 06/30/2024 C10, C46, C39, B
Date