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San Joaquin County Environmental Health Department <br /> CONTRACTOR AUTHORIZATION FORM <br /> JOB ADDRESS: 16400 Golden Valley Parkway 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.V�Je,St <br /> Contractor Name: �,Xokrxhm It, <br /> License#: Expiration Date: <br /> Signature: Title: - Pres id-e4 Z- <br /> Print Name: ,, IZr�re jt/ �,{/��{ �� Z Date: �2 <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 /> 0 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 /> EEPJII 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: n Policy#: �ZU ZSD g Exp. Date: Q)12023 <br /> IASVVAna fvno <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 c mply 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 /> I, hndrekl , hereby authorize <br /> Name of C•57 licensed lAuafide,?, <br /> sentative Prim Name 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 ad is limite to <br /> work plan dated on the front page of this application. <br /> Signature of C-57 Licensed Authorized Representative <br />