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Sig lure of C-57 Licensed Authorized Representative <br />San Joaquin County Environmental Health Department <br />CONTRACTOR AUTHORIZATION FORM <br />JOB ADDRESS: 3) • )()Wo'S 1`-k4ZA\ (,0j C,Qtat-e PERMIT WP #: <br />N ()() Cllk6YY1(0, 31 ' <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: <br />License #: <br />A. ki ',— <br />Signature: <br />Print Name: P+Moitd,o, VA Goo cpCk <br />Expiration Date: Q;1160 / 2623 <br />Title: PdVil .1Y1 Skr GLA-Ati€ N0,04f /0Wiger <br />Date: 101GI <br />XC2 (W C2e0 110;uno, <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 />provided for by Section 3700 of the Labor Code, for the performance of the work for which this <br />permit is issued. <br />13/ 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 />Carrier: 3k-a \-Q -03/1a Policy #: cib5cA 2(B -26 2( Exp. Date: <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 sub.ect to workers' compensation provisions of Section 3700 of the Labor Code, I shall <br />forthwith se provisions. <br />Signature: <br />Print Name: b VW-N(1_0)(X <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 FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />A ,N-104.ck 1.\-(inu90% , hereby authorize u30,\A-0,,Le V-4.1'n\ C\W-A 01/4•43 <br />Namo of C-57 LICenSed Authorized Representative <br />Print Nemo of Authorized Agent <br />to sign this San Joaquin County Well & Boring Permit Application on my behalf. I understand this <br />authorization is valid for one year and i ited to the work plan dated on the front page of this application. <br />2/ 20 2.7_