2068 S NINTH STPermit Types
OLD ELE MEC PLM
X X
Permit Number: BLD2022-06119
Issued: 05/16/2023
www.iinaheim.net/building
(714)765-0626
Quarter Section: 67
Site Address: 2068 S NINTH ST, ANAHEIM, CA 92802
Legal Description: N TR 2575 BLK LOT 14
APN: 09053104
CITY OF ANAHEIM
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 3705 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 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.
�nq I have and will maintain workers compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which
J7 �" this permit Is Issued. My workers Compensation insurance carrier and policy are:
Cartier: AMERICAN ZURICH INSURANCE COMPANY Policy No.: EWS107456505 Expiration Date:10131/2023
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 cornnation laws of California, and agree that, if I should become subject to the workers compensation provisions of Section 3700 of the
-zAnI shall to mply with those provisions.
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Signature of Applicant Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
1 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:
1 hereby affirm under the penalty of Perjury that 1 am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions , and lice s in full force and effect.
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Contractor Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE (S)
688104 12/31/2022 C46, B, C10. C39, C36