5044 E HOLBROOK STPermit Types
BLD ELE MEC PLM
X
Permit Number: BLD202340069
Issued: 01/09/2023
www.anaheim.net/building
(714)765-4626
Quarter Section: 171
CITY OF ANAHEIM
Site Address: 5044 E HOLBROOK ST, ANAHEIM, CA 92807
Legal Description: N TR 6686 BLK LOT 64
APN: 34321202
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 ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED
FOR IN SECTION 3706 OR THE LABOR CODE. INTEREST, AND ATTORNEYS FEES.
1 hereby affirm under penalty of perjury one of the following declarations:
1 have and will maintain a certificate of consent to selfansure 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.
1 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 worker's Compensation insurance carrier and policy are:
Cartier. AMERICAN ZURICH INSURANCE COMPANY Policy No.: WC900086112 Expiration Date: 12131Q023
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, it I should become subject to the worker's compensation provisions of Section 3700 of the
Labor de I shall fo with comply with those provisions.
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Signature of App isDate
6110GIz3
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 Code, , y license I In full force and effect.
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G�ontractor Signature V Date
NUMBER EXPIRATION DATE LICENSE TYPE (S)
643700 06/30/2024 C39, B