8347 E QUIET CANYON CTPermit Types
BLD ELE MEC I PLM
X X X
``Permit Number: BLD2023-00153
Issued: 02/15/2023
www.anaheim.net/building
(714)765-4626
Quarter Section: 227
CITY OF ANAHEIM
Site Address: 8347 E QUIET CANYON CT, ANAHEIM, CA 92808
Legal Description: N TR 14190 BLK LOT 2
APN: 35447214
WORKER'S COMPENSATION DECLARATION:
BUILDING DIVISION o
200 S. ANAHEIM BLVD. '
(714) 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 ATTORNEYS 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:
Carrier ACE AMERICAN INSURANCE COMPANY Policy No.: C51275652 Expiration Date: 11/1/2023
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
worker's compensation laws of California, and agree that, if I should become subject to the workefs compensation provisions of Section 3700 of the
Labor Code, I shall forthwith comply with those provisions.
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Signature of Applicant Date I
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 Division 3 of the Business and
Professions Code, and my license Is In full force and effect.
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Contractor Signature
NUMBER EXPIRATION DATE LICENSE TYPE (SI
463944 08/31/2022 B. C16
al 15 j ao��
Date