8635 E SILVER RIDGE LNPermit Types _
BLD ELE MEC PLM
X
Permit Number: BL62023-00064
Issued: 01/09/2023
www.anaheim.net/building
(714)765-4626
Quarter Section: 226
CITY OF ANAHEIM
Site Address: 8635 E SILVER RIDGE LN, ANAHEIM, CA 92808
Legal Description: N TR 14076 BLK LOT 20
APN: 51403110
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765-6163
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 ATTORNEYS FEES.
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certificate of consent to self4nsure 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.
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 are:
Cartier. ACE AMERICAN INSURANCE COMPANY Policy No.: MUC68916446 Expiration Date: 3/112023
Name of Agent: Phone No.:
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 California, and agree that, if I should become subject to the workers compensation provisions of Section 3700 of the
bor Cod shall f with comply with those provisions.
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 CONT 'TOWS DECLARATION:
1 hereby affirm and he penalty of P?Jmq4kt I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions Cod , and T
y license i n full forcAand effect. rr
� 913
Contractor Signature Date
NUMBER EXPIRATION DATE
602331 09/30/2022
� SICENSE TYPE ISIT PE IS
C10, B. D12, C-2, C39, C-6, C17, C36, D34,041, D24