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San Joaquin County Environmental Health Department <br /> CONTRACTOR AUTHORIZATION FORM <br /> JOB ADDRESS: 'Avei"010D7 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: N,,J 4FpA � �0 <br /> License#: 4,/A5 7,;A 9 ExpiratiAS <br /> n Date: <br /> Signature: �.� Li'�✓ Title: iye.v i <br /> Print Name: j;i ty< C'A"ejok Date: -7/,-1 <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 /> 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;&,oe p-e-"A /N6. C. - Policy#:44-7y4 r Zo--b!-4b Exp. Date: <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 /> Signature: <br /> Print Name: 1 cK D/J— <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 ,hereby authorize <br /> Nem.olGS761—w--a Kopmenutwe Ptint Name OfAuthott WApertt <br /> to sign this San Joaquin County Well& Boring Permit Application on my behalf.I understand this <br /> authorizatioli is valid for one year and is limited to the work plan dated on the front page of this application. <br /> gnetum of S7 conso utho rad Reproson e <br />