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PUBLIC ftiALTH SERVICES <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DIVISION <br />Ernest M. Fujimoto, M.D., M.P.H., Acting Health Officer <br />445 N. San Joaquin Street • P.O. Box 388 • Stockton, CA 95201-0388 <br />(209) 468-3420 <br />WAIVER IN LIEU OF WORKERS' COMPENSATION <br />(WHEN YOU DO NOT HIRE EMPLOYEES) <br />This waiver form 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 persons) other than licensed contractors are on the job - <br />site. <br />/9 <br />CONTRACTOR LICENSE NO: <br />BUSINESS NAME: 1 t <br />PLEASE PRINT <br />i <br />S <br />BUSINESS ADDRESS: ( Q Li W V c�(A lv <br />PHONE NO.:_(N) H ion <br />I certify that in the performance of any work for which a permit is issued by the San <br />Joaquin County Environmental Health Division, I shall not employ any person in any <br />manner so as to become subject to the Workers' Compensation Laws of California. <br />I 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 />SIGNATURE DATE <br />NAME (TYPED or PRINTED) <br />A Dilisiun "I San ,loaquin Cnun17 HcJlh Care .Set, ice, <br />