4412 E ORANGE CREEK LNPermit Types
BLD ELE MEC FPLM
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Permit Number: BLD2022-05816
Issued: 12/08/2022
www.anaheim.net/building
(714)765-4626
Quarter Section: 163
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(7141765-5153
Site Address: 4412 E ORANGE CREEK LN, ANAHEIM, CA 92807
Legal Description: N TR 9792 BLK LOT 4
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APN:36135229
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 self -Insure 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.
I have and will maintain workees 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 carder and policy are:
Cartier: ACE AMERICAN INSURANCE COMPANY Policy No.: WCUC68916446 Expiration Date: 31112023
Name of Agent:
Phone No.:
I certify thrthormance 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
worker's os of C ia, and agree that, it 1 should become subject to the worker's compensation provisions of Section 3700 of the
Laborh co ply It ose provisions. q ff
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):
Lender's Name:
Lender's Address:
LICENSED CONTOR'S DECLARATION:
I hereby affirm and a penalty of Perjury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions Cod ,and y license Is In fu nd effect.
IZI"f".
Contractor Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE (S)
602331 09/30/2022 C10, B. D12, C-2, C39, C-6, C17, C36, D34, D41, D24