Laserfiche WebLink
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: '`rV�, ( o(-S-� �xj�%G1�Gt ,� lel 'y -'L <br />License #: U 0 Expiration Dater <br />Signature: ! Title: PVe_S i Ckk-+n <br />Print Name: �l �1 Q. (/�$.l�l�l �l (� Z 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 />E3 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 />�� U /r Q /2- <br />+UCarrier: {- � 11.SuYd(mi Policy #: q Z U � U G Exp. Date: 0 9 <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 />fo with c:o 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 />r1 <br />AUTHORIZATI <br />ON FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />I, An(re (� E? V I1 -L 6yv;& z_ ,_hereby authorize <br />Name d CS UJ W1dALth.L-d Rep—*,dMw Pfkt Naw of AWMrimd Agwt <br />to sign this San Joaquin County Well & Boring Permit Application on my behalf. 1 understand this <br />authorization is valid for one year anjis limited to the wo c plan dated on the front page of this application. <br />s�,ae.. m td7 lioentad Autn,ized RaprvaYative <br />