Laserfiche WebLink
San Joaquin County Environmental Health Department <br />CONTRACTOR AUTHORIZATION FORM <br />JOB ADDRESS: S Tinnin Rd <br />PERMIT WP #: <br />LICENSED CONTRACTORS DECLARATION <br />I hereby affirm that I am licensed under the provisions of Chapt 9 (commencing with Section 7000) of <br />Division 3 of the California Business and Professions Code an.0 my license is in full force and effect. <br />Contractor Name: <br />GEO-EX SUBSURFACE EXPLORAr�DON <br />License #: 954267 :tExpiration Date: 07/31/2022 - <br />.rt � <br />Signature: R" Title: C/ {)"dC✓r(— _ <br />Print Name: THOMAS REW p �T �. , Date. <br />WORKERS' COMPENSATIO�-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 />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: STATE COMPENSATION INS FUND Policy #: 9053901 Exp. Date: 11/29/2022 <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 />forthwith comply 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 />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />1, , hereby authorize <br />vama of C-57 Licansed Aulnorizod ReprosenUtivc P-1 Ns 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 is limited to the work plan dated on the front page of this application. <br />Signawro @ C4? Licenied-Aadh4; ued -114 sentative <br />