Laserfiche WebLink
PAGE 02 <br /> MAR 4 '93 12:54 FROM <br /> PUBLIC '-HEALTH SERWES <br /> SAN JOAQUIN COUNTY s <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Ernest M. Fujimoto, M.D., M.P.H., Acting Health Officer <br /> 445 N.San Joaquin Street a P.O. 8m 3888 • Stockton,CA 95291.6388 <br /> (209) 468-3426 <br /> WAIVER IN LIEU OF WORKERS' COMPENSATION <br /> (WHEN YOU DO NOT HIRE EMPLOYEES) <br /> This waiver forth is to be submitted In lieu of a Workers' Compensation Certificate. <br /> Please be advised, this waiver form means you do not hire any employees, therefore, <br /> you will be in violation if any person(s)other than licensed contractors are on the job- <br /> site. <br /> PLEASE PRINT <br /> DATE: March 4 1298 <br /> CONTRACTOR LICENSE NO: 746468 <br /> BUSINESS NAME: Mr. B'& Enterprises <br /> BUSINESS ADDRESS: P.O. Box 31600 Stockton, Ca. 95213 <br /> PHONE NO.:_( 203 942-3131 <br /> I certify that in the performance of any work for which a permit is issued by the Sart <br /> Joaquin County Environmental Health Division, 1 shall not employ any person in any <br /> manner so as to become subject to the Workers' Compensation Laws of California. <br /> 1 understand that if, in the performance of any work for which any permit is issued, <br /> I become subject to the Workers' Compensation Laws, I shall comply with those laws <br /> or the permit shall be deemed revoked. <br /> March 4, 1998 <br /> SIGNATURE DATE <br /> Richard O. Bywater <br /> NAME (TYPED or PRINTED) <br /> A F),66n d Inn J-41lic Cnunl)11cWth COM'k"h . <br />