2449 E PARADISE RD (4)Permit Types
BLD EE MEC PLM
X X EF
Permit Number: BLD2023-01350
Issued: 05/02/2023
Www.anaheim.net/building
(714)765.4626
Quarter Section: 113
Site Address: 2449 E PARADISE RD, ANAHEIM, CA 92806
Legal Description: N TR 2490 BLK LOT 17
APN:08337122
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(7141 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 ATTORNEYS 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 workers compensation insurance, as required by Section 3700 of the tabor Code, for the performance of the work for which
this permit is issued. My workers Compensation Insurance carrier and policy are:
Cartier: AMERICAN ZURICH INSURANCE COMPANY Policy No.: EWS107456505 Expiration Date: 10[3 112023
Name of Agent: Phone No.:
I certify that ie 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
Trk5es cora nsation laws of California, and agree that, if I should become subject to the workers compensation provisions of Section 3700 of the
shall forthh, f h comply with those provisions.
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 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
Professions Code, and my nse is in full force and effect.
s - G 3
Contractor Signature Date
<J—
NUMBER EXPIRATION DATE LICENSE TYPE (S)
888104 12/31@024 C46, B. C10, C39. C36