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San Joaquin County Environmental Health Department <br /> CONTRACTOR AUTHORIZATION FORM <br /> � `4� <br /> JOB ADDRESS: ZO Z2'? ^f• �C;7,rel f�• �i�loN i.4I q'i5V 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: NNAefh-'' �P N3 /NC. <br /> License#: Expiration Date: >�Lo)L 2- <br /> Signature: Title: P�PA4.,.o / <br /> Print Name: /L'Ky C'A�y�prj Date: 40/`I/?-o <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 /> .,c I have and will maintain workers'compensation insurance, as required by Section 3700 of the <br /> I�+ 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:A V Policy#:4-?0a2P_P/-D8 Exp. Date: <br /> 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 /> hereby authorize <br /> Name of C37 Llunwd AuVwltad Rr prrsenWa Point Nam of AuthorWd Aap t <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 Zflted to the work plan dated on the front page of this application. <br /> f <br /> Slgnatun sW ArM..d R.PM-M. <br />