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San Joaquin County Environmental Health Department <br /> CONTRACTOR AUTHORIZATION FORM <br /> JOB ADDRESS: 0 01 Dr7 t 0 . 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 kCalifornia Business and Professions Code and my license is in full force and effect. <br /> Contractor Name: Ific, <br /> License#: 1l S Expiration Date: dTl 2U2g <br /> Signature: Title: nfl r <br /> �n ,, V <br /> Print Name: Ur L Gti Gt71 Date: Z,l 12-6 Z-(D <br /> T <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 hereby affirm winder penalty of perjury one of the follo frog 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: SAAA-L fl> P01icy#: Exp. Date: 91 i U <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 b subject to the workers' compensation law of California, and agree that if I <br /> should become sub' ct to wo ers' compensation provisions of Section 3700 of the Labor Code, 1 shall <br /> forthwith comply with those provisions. <br /> Signature: <br /> Print Name: I�� <br /> i <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 /> N—of Cd7 U—d A.&.hzad Rpnsw%wl" MM Name of&At—lnd Agri <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 /> togneum of Z•5I i--d u M nzao Np—ms <br />