824 CALLE VENADO (3)Permit Types
BLD ELE MEC PLM
X
Permit Number. BLD2022-04746
Issued: 10/0612022
www.anaheim.net/building
(714)765-4626
Quarter Section: 205
Site Address: 824 S CALLE VENADOANAHEIM, CA 92807
Legal Description: N TR 8375 BLK LOT 63
APN:36507104
CITY OF ANAHEIM
BUILDING DMSION
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 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 issued.
I have and will maintain workers compensation insurance, as required by Section 3700 of the labor Code, for the performance of the work for which
Ir/I.—J this permit is issued. My workers Compensation insurance carrier and policy are:
Cartier. AMERICAN ZURICH INSURANCE COMPANY Policy No.: WC614287601 Expiration Date: 10/1/2023
Name of Agent: Phone No.:
1 certifythat 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 I ws of California, and agree thatif I should become subject to the workers compensation ation provisions of Section 3700 of the
Labor Code, I shall to
1 , th comply with those provisions. /�1
I
gnature 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.Cly.C):
Lender's Name:
Lender's Address:
)/CONTRACTOR'S DECLARATION:
under the penalty of Perjury am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Code, and my license is in full and effect.
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Date
NUMBER EXPIRATION DATE LICENSE TYPE (S)
750184 06/30/2024 C10, C46, C39, 6