6500 E PASEO CABALLOPermit Types
BLD ELE MEC PLM
X
Permit Number: BLD2022-05975
Issued: 12/19Q022
www.anaheim.netibuilding
(714)765-4626
Quarter Section: 204
CITY OF ANAHEIM
BUILDING DMSION
200 S. ANAHEIM BLVD.
(714)765-5153
Site Address: 6500 E PASEO CABALLOANAHEIM, CA 92807
Legal Description: P BK 63 PG 9 PAR 1 TR 8215 LOT 43 POR OF LOT (P M
APN: 36504112
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 hemby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certificate of consent to self4nsure 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 worker's 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 carrier and policy are:
Cartier. ZURICH AMERICAN INSURANCE COMPANY Policy No.: WC140631702 Expiration Date: 6/1/2023
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 ooripensation laws of California, and agree that, if I should become subject to the worker's compensation provisions of Section 3700 of the
Code, l shall.forthwith comply with those provisions.
1 2
Signature of AppUCant 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):
Lenders Name:
Lenders 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 DNislon.3 of the Business and
Professions Code, and my license is In full force and effect.
c
Contractor Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE (S)
1007845 10/31/2023 C39