117 S ALICE ST (2)Permit Types
BLD ELE MEC PLM
X X
Permit Number: BLD2023-01110
Issued: 05/04/2023
wwmanahelm.net/building
(714)765-0626
Quarter Section: 133
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(7141765.5153
Site Address: 117 S ALICE ST, ANAHEIM, CA 92806
Legal Description: N TR 6138 BLK LOT 20 ;
APN:26801111
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.
1 hereby affirm under penalty of perjury one of the following declarations:
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 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 pf California, and agree that, If I should become subject to the workers compensation provisions of Section 3700 of the
Labor Code,1 shall forOmwi fy wtOr those provisions.
' � V
TgrWre 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).
Lender's Name:
Lender's Address:
3ED CONTRACTOR'S DECLARATION:
affirm under the penalty of Pe ury that 1 am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
)ns Code, and my license Is 1 I force and effect.
1 96
or Sign Date
NUMBER EXPIRATION DATE LICENSE TYPE (S)
750164 06/30/2024 C10, C46, C39, 6