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f <br /> San Joaquin County Environmental Health Department <br /> CONTRACTOR AUTHORIZATION FORM <br /> JOB ADDRESS: I�I Str-h j S )owV Rf ve r 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: SC�js�� �Of, (�Y� <br /> License#: C64 _ Expiration Date: <br /> Signature: - Title: C2S�d <br /> Print Name: _Date: 9 Z <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 /> 13 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 /> M/ 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 /> Carrier: nc Policy#: 905 0` Exp. Date: i l JZC7 <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 become subject to workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> ----— <br /> Signature: <br /> Print Name: <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL <br /> SUBJECT AN EMPLOYER ITO 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 FOR O HER THAN C-57 SIGNING PERMIT APPLICATION <br /> 0 c7 hereby authorize ccQ/ V ���12_1 <br /> amo irn+:d�wF&7adR.pn��nww_ __-_._ - <br /> m Name• um <br /> to sign this San Joaquin County 4ell&Boring Permit Application on my behalf.1 understand this <br /> authorization is valid for one year and Its limi d to the wnrk Ip an dated on the front page of this application. <br /> l <br /> b,: <br />