4446 E ADDINGTON DR (10)Permit Types
BLD ELE MEC PLM
X
Permit Number: BLD202 05817
Issued: 12/08/2022
www.anaheim.net/building
(714)765-4626
Quarter Section: 167
CITY OF ANAHEIM
Site Address: 4446 E ADDINGTON DR, ANAHEIM, CA 92807
Legal Description: N TR 4427 BLK LOT 43
APN:35911319
WORKER'S COMPENSATION DECLARATION:
BUILDING DMSION
200 S. ANAHEIM BLVD.
(7141 765 - 5153
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 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:
Carrier: ACE AMERICAN INSURANCE COMPANY Policy No.: WCUC68916446 Expiration Date: 3/1/2023
Name of Agent:
Phone No.:
1 po 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 compeng2lItion laws of California, and agree that, if I should become subject to the worker's compensation provisions of Section 3700 of the
bor Cod shall fo with comply with those provisions.
III )4ZL
Signature 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:
LICENSED CONT TORS DECLARATION:
I hereby affirm or the penalty 9WA4tq that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions ado, nd my liven is in full and effect.
Contractor Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE (S)
602331 09/30/2022 C10, B. D12, C-2, C39, C-6, C17, C36, D34, D41, D24