205 N VIA CORTEZ (2)Pe mdl Types
BLD ELE MEC PLM
X
Permit Number: BLD2022-05403
Issued: 05/09/2023
www.anahelm.netlbuiiding
(714)765.4626
Quarter Section: 185
Site Address: 205 NN_IA CORTEZANAHEIM, CA 92807
Legal Description: P BK 225 PG 20 PAR 1
APN:35819110
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 785.5153
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 (5100,000). IN ADDITION TO THE COST OF COMPENSATION. DAMAOES AS PROVIDED
FOR IN SECTION 3708 OR THE LABOR CODE. INTEREST, AND ATTORNEY'S FEES.
1 hereby affirm under penalty of perjury one of the fdlowlrrg dedara0aro:
I have and will maintain a oaANleate of Consent to selfansure for workers 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 In .
!X) I have and will maintain workefa compensation Insurance, as mWIred by Section 3700 of the Labor Code, for the performance of the work for which
this permit is Issued. My workefs Compensation insurance carder and policy are:
Carder ZURICH AMERIgM INSU88M COMP Policy No.: WC34872ea14 Expiretion Date:
Name of Agent: {r i 5 1 [4 ^1�'f[ �� Phone No.:c%{� ��.� �9 " ()y
I certify that In the performance of the work for which this permit is Issued. l shell not employ any person In any manner so as to become wNed to the
workefe ownpensa0on laws of California. and agree that If I should become su*d to the workers compensation provisions of section 37W of the
labor Cade. I stud forthwith comply with those provislons.
'JAC 5 11 O kazz,
Sign ure of ApplignU Pete)
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
I hereby affirm under penally 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: I
Lender's Address: 1 � ` tv
LICENSED CONTRACTOR'S DECLARATION:
1 hereby eSirm under the penalty of Perjury that I am licensed under preWslons of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professlons Code, and my license Is In tWi force and effect.
,��fn Gj 102v\'
{Contractor Signature i
NUMBER EXPIRATION DATE LICENSE TYPE IS
1021440 1213112022 C311 C10, B
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