775 S ROCK GARDEN PLPermit Types
BLD ELE MEC PLM
X X
Permit Number. OLD2622-05393
Issued: 12/02/2022
www.anaheim.net/building
(714)7654626
Quarter Section: 208
CITY OF ANAHEIM
Site Address: 775 S ROCK GARDEN PL, ANAHEIM, CA 92808
Legal Description: N TR 12690 SLK LOT 61
APN: 35443127
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 CML 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 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.
r 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:
y Carrier. AMERICAN ZURICH INSUReNGE rO6IPAh^' Policy No: WC614207601 Expiration Date: 10/1/2023
Name of Agent: ' ` Phone No.: — "---
I certify that In the performance of the work for which this permit is issued, 4 shall not employ any person In any manner so as to become subject to the H
worker's compensation laws of California, and agree that, if 1should become subject to the worker's compensation provisions of Section 3700 of the —'—
Labor Code, I shall forthwith comply with those provisions. -
Signature of Applicant• --
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:°
^.:aA4y sffirm ander-penalty-of polury-that-there Isa-censuustioa bon
(Sec.3097.Civ.C): f4NeweActewvhich4h1s pemnit•is ssuea
Lender's Name:
Lenders Address:
T 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 ii s in full force and effect
_Contractor Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE (Sl -
750184 06/30/2024 C10. C46, C39, B