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San Joaquin County Environmental Health Department <br />CONTRACTOR AUTHORIZATION FORM <br />JOB ADDRESS: q3 1a r $,�%r.,,hr iw- i, cA 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: /V-1 / /rc) L t 1JU C_-0 LLG <br />License M (� ,� `� Expiration Date: <br />Signature: Title: PrGS i C6 <br />Print Name: �t4t i4d 'k r Date:11 <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (check one) <br />�2,0�, <br />I have and will maintain a certificate of consent to self -insure for workers' compensation, as <br />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 />J Labor Code, for the performance of the work for which this permit is issued. My workers' <br />compensation insurance carrier and policy numbers are: G ��q <br />Carrier: / ^ /�'1 _ _ Policy #: �` ` M _ v Exp. Date: /0/1,2/2.2, <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 bcome subject to the workers' compensation law of California, and agree that if I <br />should become workers' compensation provisions of Section 3700 of the Labor Code, 1 shall <br />"070 <br />160with comply with those provisions. <br />Signature: <br />Print Nam <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL <br />SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML 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 />,hereby authorize /�/�'�,�' <br />--to sibrYthWSa6'J16Aq lri Coufity Well g Permit App l on on my behalf. I understand this <br />authorization is valid for one year and is ' ite t work an ated on the front page of this application. <br />i1 <br />