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San Joaquin County Environmental Health Department <br />CONTRACTOR AUTHORIZATION FORM <br />JOB ADDRESS: 3`r t h; c:�; ww��C��uC r`r, . �� ,� , �q 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: d J /rc ) 11'1JU C-0 - LLG <br />License Expiration Date: 913 / Z9, e) 3— <br />t <br />Signature: Title: P%s (V L' f <br />Print Name: (}t -i i4um jo It 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 />0 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 />.b' Labor Code, for the performance of the work for which this permit is issued. My workers' <br />compensation insurance carrier and policy numbers are:V ��� qI <br />Carrier: 54-fc-6/ 1-M _ Policy #: ��` �� Exp. Date: <br />1 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 become7170 <br />workers' compensation provisions of Section 3700 of the Labor Code, I shall <br />fopwith comply with those provisions. <br />Signature: <br />Print Nam �___, "AA: <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 _7 <br />MM ft� of wmoMa <br />-10 si§rYtb Sah'J16AgW Coufify_ Well g Permit Appl ion 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 />.1/7� <br />