1768 N WOODWIND LN (9)Permit Types
BLD ELE MEC PLM CITY OF ANAHEIM
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Permit Number: BLD2022-05372 BUILDING DIVISION
200 S. ANAHEIM BLVD.
Issued: 11/10/2022 (7141 765 -5153
www.anaheim.net/building
(714)765-4626
Quarter Section: 165
Site Address: 1768 N WOODWIND LN, ANAHEIM, CA 92807
Legal Description: N TR 5989 BLK LOT 31
APN: 34307101
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 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 workers Compensation insurance carrier and policy are:
Cartier: OLD REPUBLIC INSURANCE COMPANY Policy No.: MWC3141513 Expiration Date: 101112023
Name of Agent:
Phone No.:
I certify that in the performance of the work for itis issued, I shall not employ any person in any manner so as to become subject to the
worker's compensation laws of Califomi nd agree that, if I sho d become subject to the workers compensation provisions of Section 3700 of the
Labor Code, I shall forthwith comply a provislons.
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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:
Lenders Address:
LICENSED CONTRACTOR'S DECLARATION:
I hereby affirm under the penalty of Perjury that I a censed under provis �s of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full fo and•effecs.
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Date
NUMBER EXPIRATION DATE LICENSE TYPE IS!
990416 07/31/2023 B, C17