1233 N THURSTON PL (2)Permit Types
BLD ELE MEC PLM
X X
Permit Number: OLD2023-00900
Issued: 04/07/2023
wwmanaheim.net/building
(714)765-4626
Quarter Section: 189
CITY OF ANAHEIM
Site Address: 1233 N THURSTON PL, ANAHEIM, CA 92807
Legal Description: N TR 7450 BLK LOT 58
APN: 34943123
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 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.
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
FA this permit is issued. My worker's Compensation Insurance carrier and policy are:
Carrier: AMERICAN ZURICH INSURANCE COMPANY Policy No.: EWS107458505 Expiration Date: 10/31/2023
Name of Agent Phone No.:
I certify that In the perfo nce 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 mpensation of California, and agree that, If 1 should become subject to the workers compensation provisions of Section 3700 of the
r e. I shall f mpy those provisions.
41/71-2-3
`Signature of Applicant 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):
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 Cc , a my I nse Is in force effect
Contractor Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE (S)
888104 12/31/2024 C46, B. C70, C39. C36