6415 E VIA ARBOLESPermit Types
BLD ELE MEC PLM
X X
Permit Number: BLD202n4640
Issued: 01/30/2023
www.anaheim.net/building
(714)7654626
Quarter Section: 197
Site Address: 6415 E VIA ARBOLESANAHEIM, CA 92807
Legal Description: N TR 13692 BLK LOT 8
APN:35620212
CITY OF ANAHEIM
BUILDING DMSION
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 declarations:
I have and will maintain a certificate of consent to selfinsure 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 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: ZURICH AMERICAN INSURANCE COMPANY Policy No.: EWS107458504 Expiration Date:0� /31/2022
Name of Agent: Phone No.:
I 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
become subject to the worker's compensation provisions of Section 3700 of the
JL5 c7 /2- -2,
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 Cod , and my lice Is In full me an ffect.
Con ractor Signature
NUMBER EXPIRATION DATE LICENSE TYPE (S)
888104 12/31/2022 C46, B, C10, C39, C36
Date "
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