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Sent By: Gregg Drilling & Testing -nc.; 925 313 0302; Mar-15-r'"- 8:39; Page 1 /1 <br /> �..,`. ..t_..nuu �•�ev L'Ad 1 t�tCir/1 u4ju SECOR-SACRAMENTO <br /> `.,i Q Q U 2 <br /> 84/14/7860 12:25 2a94683433 FIFTM FLOOR PAGE 04 <br /> San°3ki��osiatarlii�ivTcc�n�pccta ��lkt�i}'`3�eS"rvlc�es'•lJ�i�:tV::Wls11, ... S�CpP!r4r'S�+ent- <br /> Re <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby oform that I am licensed udder the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Businosa and Professions Code and my fieertse is in full force and effW. <br /> License#: ��S /(p Expiration Dater: <br /> Date: 1 L-{ 1 7) 1 Contractor: C- <br /> Signature: re% <br /> Prin"name: Lia' A U)Lld n <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 hereby affirm under penalty of perjury ane of the following declarations: (CHECK ALL TI4AT APPLY) <br /> I have and MMI maintain a csrtificate of consent to self-insure for workers'Compensation, as provided for by <br /> �on 3700 of the Labor Code,for the performance of the work for Which this permit is issued. <br /> e and will mflinteln workers'cornpenm6on Insurance,as required by Section 3740 of the Labor Code, <br /> for the performance of the work for which this permit is issued- MY workers'compensators Insurance <br /> carrier and policy numbers are: <br /> Carrier. <br /> �c -1,4 -e-f,- f olicy Number: N� r7(i 5" <br /> 1 I oartlfy that in the pedomranee of the work for which this permit is issued. I shah not employ any person in <br /> any manndr 8o as to became subject to th9 workers'cornpensa0on laws of California,and agree that if I <br /> should become subleet to the workers'compensation puvisions of Section 3700 of theLabor Code. I shall <br /> forthwith comply with those provisions. <br /> Bate: signature: <br /> Printed Name: <br /> rYt ar Gc. ld a <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSiATiON COVERAGE IS UNLAWFUL,AND SHALL GUBJECT <br /> AN EMPLOYER TO CRI�NNAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.) i�DN TION To HIF COSTHE IAN ATION.INTEREST,ATTORNEY'S FEES,AM t]A111AGt <br /> pROvIDED <br /> fiJ , ` ¢ G87 licensed ruthertmd representative),hereby <br /> aunwrizerd <br /> i <br /> ba sign this San Joaquin Ccunpr 1Alel1 Panni!Age <br /> tieetlon an my beh®If. 1 understand this authorization is valid for <br /> ane 1 year and is limited 10 the work tart dated an the front of this a lication. <br /> 1 <br />