7690 E PASEO LAREDOPermit Types
BLD ELE MEC FLM
X
Permit Number. BLD2022-05384
Issued: 11/14/2022
www.anaheim.net/buiiding
(714)765.4626
Quarter Section: 201
CITY OF ANAHEIM
Site Address: 7690 E PASEO LAREDOANAHEIM, CA 92808
Legal Description: N TR 7732 BLK LOT 31
APN: 35827302
WORKER'S COMPENSATION DECLARATION:
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(7141 765 - 5153
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 selfminsure for workers compensation. Issued by the Director of Industrial Relations as provided for by
CLSection3700 of the Labor Code, for the performance of the work for which this permit Is issued.
l � a 1 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. ZURICH AMERICAN INSURANCE COMPANY Policy No.: WC112500902 Expiration Date:12*112022
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, it I should become subject to the workers compensation provisions of Section 3700 of the
Labor Code, I shall forthwith comply with those provisions.
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SignatureApplicant 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):
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 license is in full force and effect.
Contractor Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE (S)
1059711 10/31/2023 B, C33, C39