1173 N LOTUS STPermit Types
BLD ELE MEC PLM
X X
Pencil Number: B82023-00775
Issued: 03/10/2023
www.anaheim.net/building
(714)765-4626
Quarter Section: 37
Site Address: 1173 N LOTUS ST, ANAHEIM, CA 92801
Legal Description: N TR 2093 BLK LOT 123
APN: 07241611
CITY OF ANAHEIM
BUILDING DMSION
200 S. ANAHEIM BLVD. ti
(7141765-5153
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 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 selfainsure for worker's compensation, issued by the Director of Industrial Relations as provided for by
2 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:
Cartier. AMERICAN ZURICH INSURANCE COMPANY Policy No.: W0614287601 Expiration Date: 10/1/2023
Name of Agent: Phone No.:
Ly 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
rs compensation laws of California, and agree that, i( I should become subject to the workers compensation provisions of Section 3700 of the
Code, I shall foth comply with those provisions.
Sign re of Applicant 6 Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
I hereby affirm under penally 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:
LIC SED CONTRACTOR'S DECLARATION:
1 h(rel affirm under the penalty of Perjury 9M I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
P Ions Code, and my license is in full�t;ri
deffect. /
ii. w t , i
ntractor Signatures Date
NUMBER EXPIRATION DATE LICENSE TYPE (Sf
750184 06/30/2024 C10, C46, C39, B