COMPLIANCE INFO 2004-2009 - Laserfiche WebLink

Home Browse Search

.. . ........... WORKERS' COMPENSATION DECLARATION (For Contractors Only) In January 1995, Assembly Bill No. 443 relating to Workers' Compensation took affect, which requires contractor's to carry their certificate with them. The City of Tracy is no longer required to keep copies on file and instead will require that each applicant sign the following workers' compensation declaration and, at time of Fire Prevention permit issuance, show their valid workers' compensation insurance certificate. I hereby affirm under penalty of one of the following declaration: ❑ I HAVE AND WILL maintain a certificate of consent to SELF-INSURE for workers' compensation as provided for by Section 3700 of the Labor Code for the performance of the work for. which this permit is issued. I HAVE AND WILL maintain WORKERS' COMPENSATION INSURANCE as required by section 3700 of the Labor Code for the performance of the work for which this permit is issued. My workers compensation insurance carrier and polic umber are: CARRIER: POLICY NO.: (A -��C od-) �Z( EXPIRATION DATE: 1` 1 . _ ID O (Phis section need not be completed if the permit is for one hundred(S 100)dollars or less) ❑ I certify that in the performance of the work for which this permit is issued, I SHALL NOT EMPLOY ANY PERSON in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply withthose pr - Date:��,V OA Applicant's Signa WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLA FUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO O E HUNDRED THOUSAND ($900,000)DOLLARS,IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST,AND ATTORNEY'S FEES. Side 2 of 2