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PEj JIDIA12.DRE-6A.= *ifR: 0 2- 550 / <br />gbaltairviceprfilitly;l0eil rip.l!qefori:S901rpgrion_ <br />i <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I 8M licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br />3 of the Businoca and Professions Code and my license is in full force and effect. <br />License #: Expiration Date: 1/ Lo z__ <br />Date: Contractor <br />Signature: Title: <br />Printed name: <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) . <br />I have and will rnsinbsin a certificate of conSent to self-insure for workers compensation, as provided for by <br />Section 3700 of the Labor Code, for the performance of the work for Which this permit Is issued. <br />I have and will mainteln 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 />carder and policy numbers are: <br />Carrier: Policy Number: <br /> <br />Pa <br />I certify that in the performance of the work for which this perrnit is issued, I shall nOt employ any person in <br />any manner so as to become subject tO the <br />workers' oampensatIon laws of California, and agree that if I <br />should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shalt <br />forthwith comply with those provisions. <br />Date: <br /> Signature: <br /> <br />Printed Name: <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 THg COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PsoviDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />bk.)Q...? /5- OL, 5-Ca <br />Page 1/1 <br />1002 <br />PAGE 04 <br />Sent By: Gregg Drilling & Testing, Inc.; 925 313 0302; Mar-15-01 8:39; <br />r,t iLLD *01 U440 SECOR-SACRAMENTO <br />04/1412000 12:25 2094683433 <br /> FIFTH FLOOR <br />(c-ST licensed:I authorized representative), hereby <br />auttiori2et .1711tc/A- <br />eign this San Joaquin County Wall Permit Application on my behalf. I understand this authorization is valid for <br />to <br /> one i ear and is limited to tht work Ian tiond on the front of this a lication. <br />•