824 S CALLE VENADO (2)Permit Typesi
BLD ELE MECPLM
X x
Permit Number. OLD2022.05396
Issued: 12/02/2022
www.anaheim.net/building
(714)7654626
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 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 Cods, for the performance of the work for which this permit is Issued.
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 aro:
Cartier. AMERICAN ZURICH INSU AN E COMPANY Poflcy No.: WC614287601 Expiration Date: 10/112023_
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
workers compensation laws of Catifomia, and agree that, If I should become subject to the workers compensation provisions of Section 3700 of the
Labor Code, I shall forthwith ply with those provisions.
Sig atureof Applicant
Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY.
-- "--1h reby-effiwa4mdesaconsbWion.lending agency -far -the •perk anance-ofdheArrork{
(Sec.3097.Civ.C): �penaitas Issued
Lender's Name:
Lender's Address:
LICENSED ONTRACTOR'S DECLARATION:
I hereby an der the penally of Perjury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionse, and my license is in full force and ct. _
Contra for Signature 7Date
NUMBER EXPIRATION DATE LICENSE TYPE (S)
750184 06/30/2024 C10, C46, C39, 6