8314 E QUIET CANYON CTPermit Types
BLD I ELE I MEC PLM
X I X
Permit Number: OLD2023.01113
Issued: 04/05/2023
www.anaheim.neUbuilding
(714)765.4626
Quarter Section: 227
CITY OF ANAHEIM
Site Address: 8314 E QUIET CANYON CT, ANAHEIM, CA 92808
Legal Description: N TR 14190 BLK LOT 33
APN:35447111
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.
I hereby 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.
1 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: AMERICAN ZURICH INSURANCE COMPANY Policy No.: WCC614287601 Expiration Date: 11011112023
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 I should become subject to the worker's compensation provisions of Section 3700 of the
Labor e, I shall forthwith comply with those provisions.
Signature of App scant Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
I hereby affirm under penalty of pejury 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:
LISED CONTRACTOR'S DEC RATION:
1 h y affirm under the penalty of P ury t I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
PrIt,
ions Code, and my license is full and effect.
0S�
nt ctor Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE (S)
750184 06/30/2024 C10, C46, C39, 8