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o�a�f SAN JOAQUIN COUNTY <br />COMMUNITY DEVELOPMENT DEPARTMENT <br />1810 E. Hazelton Ave., Stockton, CA 95205-6232 <br />PHONE: 2091468-3120 Fa)c 2091468-3163 <br />CERTIFICATE OF CONTRACTOR REGISTRATION <br />Matthew Thomas <br />Name of Licensee <br />(As Registered with the State) <br />5444 Dry Creek Road <br />Mailing Address <br />Sacramento / CA/ 95838 <br />City State Zip <br />State License No: 803616 <br />CGRS, Inc. <br />Also Doing Business As (DBA) <br />(As Registered with the State) <br />626-627-8316 <br />Telephone Number <br />mthomas@cgrs.com <br />1= -mail <br />Expiration Date: 1/31/2024 <br />Contractor Class: Primary A/C61/D40/D63/ Supplemental: HAZ <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations:. <br />❑ I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided - <br />for by 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 <br />Code, for the performance of the work for which this permit is issued- My Workers' Compensation <br />Insurance carrier and policy number are: <br />Carrier Pinnacol Assurance Co Policy Number 4629480 <br />❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any <br />person in any manner so as to become subject to the Workers' Compensation laws of California, and <br />agree that if 1 should become subject to the Workers' Compensation Provisions of Section 3700 of the <br />Labor Code, I shall forthwith comply with those provisions. <br />License Holder's Signature <br />Matt Thomas <br />Name (Typed or Printed) <br />6/19/2023 <br />nate <br />PERSONS AUTHORIZED TO SIGN PERMIT APPLICATIONS <br />Matt Thomas Compliance Services Manager <br />Signature Print Name and Title <br />Signature <br />Signature <br />Signature <br />LBUILDINGWANDOUMHandout 077 Cerfificate of Contractor Registraton.doc(Revisedl0-19-09) <br />Print Name and Title <br />Print Name and Title <br />Print Name and Title <br />