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San Joaquin County Environmental Health Department <br /> CONTRACTOR AUTHORIZATION FORM <br /> JOB ADDRESS: Z�2S S• �T'P�/1ro� /ed &d/ „ !.1/' PERMIT WP#: <br /> _ a <br /> I <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 Businessland Professions Code and my license is in full force and effect. <br /> Contractor Name: 1D'`f5 11V G- <br /> License#: 44AS77Y4 Expiration Date: 7/11/3 0 �-�- <br /> Signature: Title: rill Seo e-ti T <br /> Print Name: K+ek CJJEpA— Date: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> I <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 /> 0 Labor Code,for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carder and policy numbers are: <br /> Carrier: 4 LL /NSLIxE' vim` �v Policy#:3/l•'7'144 ,W-DJ Exp. Date: 7 //0 ZAPX1131-- <br /> 1 certify that in the performance of the v�rork 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: 44 �n� <br /> Print Name: ,e 4K - <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 /> l , hereby authorize <br /> Nemo of G57 Uconaoc AiMonmC Rapmaonlntiva Print Noma m Authanzod Apent <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 /> 51pnatum of GS7 Uco—o0 A=ortzod RopmeenUtivo <br />