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99 30. 75 Wethersfield CT 06109 1- OSHA 10 -ATTACH PAYROLL CERTIFICATION CARD TO 1ST CERTIFIED PAYROLL Safety and Health Card for each employee 1/1/09 O-TIME SEE WEEKLY PAYROLL REVERSE EFFECTIVE DATE EXPIRATION FOR PUBLIC SUBCONTRACTOR SIDENAME ADDRESS WORKS PROJECTS BENEFITS XYZ Corporation Connecticut Department of Labor DATE to be attached to the first Vage and Vorkplace Standards Diyision J FRINGE BENEFITS EXPLANATION P Bona fide benefits pai.

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