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Wow <br /> Dec 21 06 04: 21p RSI Drilling (530) 668-2429 p.2 <br /> DEC-21-2006 THU 03:16 PM y FAX N0. P. 03 <br /> S:,n Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> herby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of(.tie Business and Professions Code and my licenso is in full force and effect. <br /> ,,11II^ 0(,, <br /> LicE:i i,T#._ (J� � Expiration Cate: t Y � yUJ <br /> Date_ ItIlLok <br /> Contractor:IRP <br /> Slgnature:� Tine: <br /> fica Pa UdFaE: <br /> Printed name: <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 provided for <br /> bI Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> I have and will maintain workers'compensation insurance,as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued. My workers'compensation insurance <br /> carrier and policy numbers are: <br /> Carrier: Q{ C,fum- Policy Number:nn C5X5?n— <br /> I certify that in the performance of the work for which this permit is issued,1 shall not employ any person in <br /> ;,iny manner so as to become subject to the workers'compensation laws of California,and agree that if I <br /> &-hould become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: ,Signature: �-- <br /> PrintedNarne•Doy1 <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL.PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.).IN 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 /> (signature ofC-57 licensed authorized representative), <br /> hereby authorize(print nam�m-C1 Uy PV1r6k.UJ <br /> to sltlti this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br /> one(i)year and is limited to the work plan dated on the front page of this application. <br /> 8-29-(r21 MI <br /> rllvzalt),rWl <br /> rr»me <br />