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L 'UI UC EALTI SERVICES (V4 <br />SANI(1AQII1NININIPIIHdI,IIANNAIIIU.Ill1111111"12009� (I(All 1:20Ilarrlm Avr•nnr•) 0 SUKkloo, Califunda 451111 LIKB�i' <br />1 2119) 468 i 11x) <br />WAIVER IN LIEU Or WORKERS' COMPENSATION <br />(WI IEN YOU DO NOT IIIRE EMPLOYEES) <br />This waiver form Is to be submitted in lieu of a Workers' Compensation Certificate. <br />P1saa11iiba Adviand. this waiver form means you do not hire any employees, thorefors. <br />Ymtl will be In violation If any parsonle) other then licensed contractors are on the job - <br />silo. <br />PLEASE PRINT <br />DATE: <br />CONTRACTOR LICENSE NO: 14 0/� <R, 7 <br />BUSINESS NAM <br />BUSINESS ADDREss. 2 2 /DNO � L ( Ol��c7l 4 <br />i/ <br />PHONE NO.:-Zf9—/,300 <br />I certify that In the performance of any work for which a permit is Issued by the San <br />Joaquin County Environmental Ilealth 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 [fiat 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 />er the permit *belt be deemed revoked. <br />RE <br />&neh1 4417;0�*7"N� <br />NAME (TYPED or PRINTED) <br />TE <br />A 111, 1.1 .... ..I - ., I...gnln 1 aural 11, .11111 1 .,. 1J. 1 . ` ) <br />1 <br />