1116 W WAKEFIELD PL (11)Permit Types
BLD ELE I MEC PLM
X I X I X
Permit Number. BLD2022-05601
Issued: 11/23/2022
www.anaheim.net/building
(714)765.4626
Quarter Section: 67
CITY OF ANAHEIM
Site Address: 1116 W WAKEFIELD PL, ANAHEIM, CA 92802
Legal Description: N TR 3204 BLK LOT 92
APN:09045230
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 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 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.
1� Q 1 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 are:
Carrier: Policy No.: Expiration Date: (
Name of Agent LIN A 3 R N Cil 2 Phone No.: (PI) 7 O 5
1 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, it I should become subject to the workers compensation provisions of Section 3700 of the
Later Code, I shall foMrwith comply with those provisions.
Sign of Applicant
In) AW
Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
I hereby affirm under penalty of perjury that there Is a construction lending •agenW-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:
1 hereby affirm under the penalty of Perjury that 1 am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my J1306se Is in full force and effecL
Contractor Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE ISl
1082386 10/31/2023