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San Joaquin County Environmental Health Department <br />CONTRACTOR AUTHORIZATION FORM <br />JOB ADDRESS: PERMIT WP #: <br />LICENSED CONTRACTORS DECLARATION <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br />Division 3 of the California Business and Professions Code and my license is in full force and effect. <br />Contractor Name: Wes- - C 00 -S -t �x�%%G1�Gl`�,4 Vl J r)L <br />License #: (J -T 9 �"(o / Expiration Date: D � � � � Z26Z-2- <br />Signature: <br />Title: �Ye-S 1 CLLI+n <br />Print Name: &n J u- (/1i Date: <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (check one) <br />I have and will maintain a certificate of consent to self -insure for workers' compensation, as <br />C3 provided for by Section 3700 of the Labor Code, for the performance of the work for which this <br />permit is issued. <br />I have and will maintain workers' compensation insurance, as required by Section 3700 of the <br />Labor Code, for the performance of the work for which this permit is issued. My workers' <br />compensation insurance carrier and policy numbers are: <br />'(� J1 GZZ <br />Canier: ,-)+ _ -�'yk� (T\suanu Policy #: Z (J U -ZoZ Exp. Date: 0 % 2 <br />I certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br />any manner so as to become subject to the workers' compensation law of California, and agree that if I <br />should become subject to workers' compensation provisions of Section 3700 of the Labor Code, I shall <br />fo7with co ply with those provisions. <br />Signature: <br />Print Name: <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL <br />SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN <br />ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br />AUTHORIZATION Ht <br />FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />I, AnrVey_i y I� gcac//L z- , hereby authorize <br />Nm of Q&T Lkmnmd Aufforlmd RAprwrW� • of Au h""*d A"" <br />to sign this San Joaquin County Well & Boring Permit Application on my behalf. 1 understand this <br />authorization is valid for one year andjrs limited to the wo c plan dated on the front page of this application. <br />319n.0" of Cbl Liorm" Au"wa2�d Rope otab" <br />