7676 E WOODSBORO AVE (2)Permit Types
FXBLD ELE MEC PLM
X
Permit Number: BLD2023-01109
Issued: 04/27/2023
www.anaheim.net/building
(714)765-4626
Quarter Section: 194
CITY OF ANAHEIM
Site Address: 7676 E WOODSBORO AVE, ANAHEIM, CA 92807
Legal Description: N TR 7422 BLK LOT 39
APN: 35107404
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 ($700,000), 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 self -insure 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. AMERICAN ZURICH INSURANCE COMPANY Policy No.: WC6142ST601 Expiration Date: 101112023
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
worker's cc sation laws of California, and agree that, lf I should become subject to the workers compensation provisions of Section 3700 of the
I . or Code 1 all forthwith comply with those provisions.
ti 2� Z5
ignature of Applicant Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
I hereby affirm under penalty of pedury that there is a construction fending 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 y affirm under the penalty of Perjury that 1 am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
e Ions Code, and my license is in full force and effect.
Qnziti� o4 19'-7 23
C ntractor Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE (S)
750184 06/30/2024 C10, C46, C39, B