706 N ZEYN ST (7)Permit Types
BLD ELE MEC PLM
X
OW'nnit Nuifl' • BLD2023-00391
Issued: 02/16/2023
www.anaheim.net/building
(714)765.4626
Quarter Section: 71
Site Address: 706 N ZEYN ST, ANAHEIM, CA 92805
Legal Description: N TR 23 BLK E LOT 29
APN: 03508214
WORKER'S COMPENSATION DECLARATION:
CITY OF ANAHEIM
BUILDING OMSION �
200 S. ANAHEIM BLVD.
(7141 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 ATTORNEY'S FEES.
I hereby affirm under penalty of perjury one of the following declarations:
1 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
this permit is issued. My worker's Compensation insurance carrier and policy are:
Cartier. Policy No.: Expiration Date:
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 worker's compensation provisions of Section 3700 of the
Labor Code, I shall rtit comply wfth those provisions.
AftA
o�// z 3
'S nature 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):
Lender's Name:
Lender's Address:
) CONTRACTOR'S DECLARATION:
7n under the penalty of Perjuryt I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Code, and my license is in fur( oq a and effect.
2 N1 2
Date
NUMBER EXPIRATION DATE LICENSE TYPE (S)