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PUBLIC tEALTH SERVICES "q;; <br /> SAN JOAQUIN COUNTY =' z <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Ernest M. Fujimoto, M.D., M.P.H., Acting Health Officer ... <br /> 4CiFO <br /> 445 N. San Joaquin Street • P.O. Box 388 a Stockton, CA 95201-0388 10 <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 person(s) other than licensed contractors are on the job- <br /> site. <br /> PLEASE PRINT <br /> DATE: <br /> CONTRACTOR LICENSE NO: <br /> BUSINESS NAME: <br /> BUSINESS ADDRESS: <br /> PHONE NO.:–(—) <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 Division of San Joaquin County Health Care Servicer <br />