221 E WILHELMINA STPermit Types
BLD ELE MEC PLM
X X
Permit Number: BLD2022-05497
Issued: 11/17/2022
www.anaheim.net/building
(714)765-0626
Quarter Section: 82
CITY OF ANAHEIM
Site Address: 221 E WILHELMINA ST, ANAHEIM, CA 92805
Legal Description: N TR 158 BLK B LOT 17
APN:03508416
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 self4nsure 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.
3 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
this permit is issued. My workers Compensation insurance carrier and policy ere:
Cartier: FALLS LAKE FIRE AND CASUALTY COMPANY Policy No.: FLA00086506 Expiration Date: 8/15/2023
Name of Agent:
Phone No.:
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
a
coppeirLsation laws of California, and agree that, if I should become subject to the workers compensation provisions of Section 3700 of the
Ke, I shell rthwith comply with those provisions.
cant 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):
Lenders Name:
Lenders Address:
LICENSED CONTRACTOR'S DECLARATION:
I hereby affirrjfundgt the penalty of Perjury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Profess7ademy Il JIn full force and effect.
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ont ctor igna Date
EXPIRATION DATE LICENSE TYPE (S)
956749 01/31/2023 B, C20, C39, C10, ASB, D41, C17