1231 N DRESDEN PL (3)Permit Types
BLD ELE ME4m-
Pennit
X Number. 13LD202245386
Issued: 11/14/2022
www.anaheim.net/building
(714)765-4626
Quarter Section: 51
Site Address: 1231 N DRESDEN PL, ANAHEIM, CA 92801
Legal Description: N TR 3396 BLK LOT 11
APN:07338425
WORKER'S COMPENSATION DECLARATION:
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(7141765-5153
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 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 workees 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.: WC112580902 Expiration Date:1213112022
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, d 1 should become subject to the workers compensation provisions of Section 3700 of the
Labor Code, I shall forthwith comply with those provisions.
Signaturof 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:
Lenders 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 Code, end my license is in full force and effect
P gz'y'-a
Con or Signature
NUMBER EXPIRATION DATE LICENSE TYPE ISl
1059711 10/31/2023 B. C33, C39
Date