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PUBLIC H EALTH SLRWES 6col <br /> SANJOAQ10N(OIINIcpad KI IAN NA Nil),AI P II <br /> Ilr.dih OIliuer <br /> 1'11 11oa 2W9 • ( 1601 Fast IIa>chon Avrnuc) • tiaKkinn, California 951111 4)Fdp'' ' <br /> (1(19) 468 3400 <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 /> Pleeee 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: ZZ /Voy�fnet;i2 � t4 4 ,4 I <br /> CONTRACTOR LICENSE NO: 3 Co. 1 Z 4 <br /> -S <br /> BUSINESS NAME: �� MsM <br /> * <br /> s oBLi'r�--c(A- <br /> BUSINESS ADDRESS: �k 3033 t S�coCJLLbfJ t GA Z ( j <br /> PHONE NO.:_(ZD ) 14. 3 14`1 <br /> 3 <br /> 1 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 /> T E DATE <br /> i�An�s � I'Ia(3Lj <br /> NAME (TYPED or PRINTED) <br /> A ..I I- I...�nin�uunry ItruhL� w 4nni. ` , <br />