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i <br />San Joaquin County Environmental Health Department <br />i� <br />CONTRACTOR AUTHORIZATION FORM j! <br />JOB ADDRESS: .X73 6I S S�ck� °� 1 asp/r Gpi4- PERMIT WP #: <br />LICENSED CONTRACTORS DECLARATION <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7400) of <br />Division 3 of the California Business and Professions Code and my license is in full force ande ect. <br />Contractor Name: <br />I <br />License Expiration Date: 7 /p�?-o ?- <br />Signature: Title TjlL SSD c•v �-- <br />Print Name: rCK C4-.v,EP1f- <br />Date: /7-Z <br />I <br />WORKERS' COMPENSATION DECLARATION <br />1 hereby affirm under penalty of perjury one of the following declarations: (check one) <br />1 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 'wh icthis <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 worke <br />compensation insurance carrier and policy numbers are: <br />Carrier: 4 LZ- / .oVSL1,eA-,v(�0 47 Policy #:41�- • 7q4", -,eV-49 Exp. Date: 71',, <br />i certify that in the performance of the work for which this permit is issued, I shall not employ anyperson in <br />any manner so as to become subject to the workers' compensation law of California, and agree %fiat if I <br />should become subject to workers' compensation provisions of Section 3700 of the Labor Code,11 shall <br />forthwith comply with those provisions. ! <br />Signature: <br />Print Name: K/ewiy� I <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, ''SHL <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 i <br />N-- of C -S! Ucomoa Autholtmtl Repro ntnUvo M.t Noma o AAWh-tWd Agent ! <br />to sign this San Joaquin County Well & Boring Permit Application on my behalf. l understand tl is <br />authorization is valid for one year and is limited to the work plan dated on the front page of this 4ppIlication. <br />Slgnobro of (:S7 Lltlwtaatl AuthonTW RapmsanblfVo <br />