1102 W PARK AVE (2)Permit Types
BLD ELE MEC PLM
X X
Permit Number BLD202245395
Issued: 12/02/2022
www.anahetm.net/building
(714)765.4626
Quarter Section: 61
Site Address: 1102 W PARK AVE, ANAHEIM, CA 92801
Legal Description: N TR 3794 BLK LOT 22
APN:03435205
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 3706 OR THE LABOR CODE. INTEREST, AND ATTORNEY'S 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.
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
this permit is issued. My workers Compensation insurance carrier and policy are:
_ Cartier. AMERICAN ZURICH INS RANCE COMP nm/ Policy No.: WC614287601 Exp
!ration
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 1 should become subject to the warkers compensation provisions of Section 3700 of the
Labor Code, I shal with comply with those provisions.
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Signatureof Applicant
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
tyol�equry ihatihereJs a construction lendla"gency-leFth"oftm ROD the wil;
(Sec.3097.Civ.C): &9emMs•issued
Lender's Name:
Lenders Address:
LICENSED CONTRACTOR'S DECLARATION:
I he 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
Prof ss ons`Code,-and my license is I force and affect. - - - - • • -
Conftwr SignatureDate
NUMBER EXPIRATION DATE LICENSE TYPE is)
750184 06/30/2024 C10, C46, C39, B