720 S RUBY LN (2)Permit T...
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D ELE MEC PLM
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MAN Number: BLD2023-00950
Issued: 02/28/2023
www.anaheim.net/building
(714)765-4626
Quarter Section: 199
Site Address: 720 S RUBY LN, ANAHEIM, CA 92807
Legal Description: N TR 10975 BLK LOT 61
APN:08566234
WORKER'S COMPENSATION DECLARATION:
CITY OF ANAHEIM
BUILDING DIVISION I , fit, �M
200 S. ANAHEIM D. -
(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 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 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. GENERAL CASUALTY COMPANY OF WISCONSIN Policy No.: 152000448 Expiration Date: 11/23/2023
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 compensation laws of California, and agree that, if I should become subject to the worker's compensation provisions of Section 3700 of the
Labor s all forthwith comply with those provisions.
Signa plicant 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 license is In and effect.
Contractor Si e
NUMBER EXPIRATION DATE LICENSE TYPE (SI
443682 11/30/2024 B. C-6
Date