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OCT 19 2005 11:24 HP LRSERJET 3200 p,4 <br />flat 18- E}rr D3:53p City of Falcon HQi~hts 85164486?S p.4 <br />'• CERTIFICATION OF COMPLfANCE <br />• ~" MINNESOTA WORKERS' COMPENSATION LAW <br /> <br />Minnesota Statute, §178.18 requires every state and local licensing agency to <br />wlthhotd rite issuance ar renewal of a license or pennif to operate a business or <br />engage in an activity in Minnesota until the appt(cant presents acc~~ptable.evidsnce of <br />compliance with the wortters' compt3nsatian insurance coverage rf,:quiremerrt of M55 <br />Chapter 176. The iMnrmation required is: the Warne of the insura~•rce company, the <br />policy number,. and cftttes of cQVerags or the. permit tc ~If-insure.. This information <br />will be collected by the licensin aaencv and retained in their files • ~ • <br />This informafaan is required by law, and licenses and penilifs to ol:~etate a business . <br />may not be reriswsd if ~ is rtQt provided. andlor is falsely reported. Furthermore, ~ . <br />this information is not provided ar falsely stated, ft may result in a •~1,Ot)0 penalty <br />assessed against the appiican# by the- Commissioner of the Departmnnk of E_aboc aad <br />Industry. . <br />Insoranca c~pany~ Name ~Li. i ~ c~s • ~ ~~5 .,~~ ~ ears ~' <br />Bates of <br /> <br />(~) <br />I am ~t regtitrsd m have workrs' camgensation liabilitq cave~age because: <br /> <br />() I have no employees <br />-() I am self-insured Cmelude pit to self-it>stim) <br />() I leave ao Employees who are covered try the workeze' compensation ;Eaw (~ese include: <br />Spora~,Pareats,C~drtn and certain farm employees) <br />I certify that the iufazimation provided above is accurate and aomlpleDe az~d that a valid <br />workers' compensation policy wilt be ]wept in eti~eet at all times as regaii ~d by ]aw. <br />r-~e~~r ~~r. <br />Name• ~Y1.S t yr + t~C,_ <br />„_~ t~ _.,x_, <br />Doing Busi~ss <br />C~,~{w} <br />j~(busi~ss name if dlffarFmtt 8,,1an yrna aema) <br />Business Address: / ~ ~~ i,/1~1,~`~'~-~. ~ ~ ~•~ i ~~~ <br />~r,~, ma.( ~s~a"~h~~. ~7~ 3~3s~ ~~~ g <br />Sigaatnre: ~ Date• _. I `~ l ~ ~" <br />