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5389 E RURAL RIDGE CIRPermit Types BLD ELE MEC PLM X I X Permit Number: BLD2023-01353 Issued: 05/02/2023 www.anaheim.net/building (714)765.4626 Quarter Section: 181 CITY OF ANAHEIM BUILDING DIVISION 200 S. ANAHEIM BLVD. (714) 765 - 5153 Site Address: 5389 E RURAL RIDGE CIR, ANAHEIM, CA 92807 Legal Description: N TR 7568 BLK LOT 85 TR 7568 LOT 85 AND POR OF LOT APN:36315211 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 this permit Is issued. My worker's Compensation Insurance carrier and policy are: Cartier. AMERICAN ZURICH INSURANCE COMPANY Policy No.: EWS107458505 Expiration Date:1013112023 Name of Agent: Phone No.: I certify that in the performance of the work for which this peril is issued, I shall not employ any person in any manner so as to become subject to the wo efs compensation laws of California, and agree that, if I should become subject to the worker's compensation provisions of Section 3700 of the 2aL)Ior C e, I she forthwith ply with those provisions. &-A 11?13 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): Lender's Name: Lender's Address: LICENSED CONTRACTOR'S DECLARATION: I hereby affirm under the penal of Perjury that i am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professioq Code/';nd my Ij�e is in full force and effect. Contractor Signature NUMBER 888104 EXPIRATION DATE 12/31/2024 LICENSE TYPE IS) C46, B. C10, C39, C36 Date