1513 W LORANE WAYPermit Types
BLD ELE MEC PLM
X X
Permit Number: BLD2023-00755
Issued: 03/21/2023
www.anaheim.net/building
(714)765-0626
Quarter Section: 59
Site Address: 1513 W LORANE WAY, ANAHEIM, CA 92802
Legal Description: N TR 2309 BLK LOT 102
APN:09051403
WORKER'S COMPENSATION DECLARATION:
CITY OF ANAHEIM
BUILDING DMSION
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.
I hereby affirm under penalty of perjury one of the following declarations:
I 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 workers Compensation insurance carrier and policy are:
Carrier. AMERICAN ZURICH INSURANCE COMPANY Policy No.: EWS107458505 Expiration Date: 10/31/2023
Name of Agent:
Phone No.:
I certify 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 compensation laws of California, and agree that, if I should become subject to the workers compensation provisions of Section 3700 of the
Labor ands, l 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 pedury 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 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
Professio Ca e, and my license is In full force and effect.
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Contractor Signat e
NUMBER EXPIRATION DATE LICENSE TYPE IS
688104 12/31/2024 C46, 6, C10, C39, C36
Date