1330 N JASMINE PL (2)Permit Types
BLD ELE MEC PLM
X
Permit Number. BLD202245011
Issued: 10/20/2022
www.anaheim.net/building
(714)765-4626
Quarter Section: 37
Site Address: 1330 N JASMINE PL, ANAHEIM, CA 92801
Legal Description: N TR 2197 SLK LOT 72
APN:07230414
WORKER'S COMPENSATION DECLARATION:
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 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.
1 hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certificate of consent to selfinsure 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.
' =• v I have and will maintain workefs compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which
this permit is Issued. My workees Compensation insurance carrier and policy are:
Carrier. AMERICAN ZURICH INSURANCE COMPANY Policy No.: WC614207601 Expirdtion Date:101112023
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, if I should become subject to the worker's compensation provislons of Section 3700 of the
Labor Code, I shall forthwith comply with those provisions.
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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):
Lenders 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 trade, and my license is in full force and effect.
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Contractor Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE ISl
750184 06/30/2024 C10, C46, C39, 6