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t4 i i�{hl I{* t. c,�ti'J...tiC CIS I?t_4:Lt1$dT1t.t`� <br />! 11on & Arlene Ruffin hcgeby affirm rmnkcr pcmhy r f perjury. the <br />^�'Trrj <br />t=�tl.�wirr� dectaratiPxr <br />I vm(y uo bcfW(o(, l)on &Ark -w Rubin__ that +luring the turn of my <br />R � f �.+(!R mw tP <br />contras for _I.CLMUC L_tL{s In%irwcticm _ Wn'iccs 1Aith Lhc Ciry of Santa AA -2, l +hill rmt <br />tetplrw any pet' n in any nutwur x, m w bmit7w %ubjovt to the wotkm' eompewmation <br />laws ofCAlifarnia. and agm that if 1 should tvcorne xahject to the wrodmn' <br />c+ompemsation prim rtom of-'SC"tiim 1700 of dic Izhur t'otie, I shall lorthuith ecunply <br />%ith thtwL pw4Worn and provide proof of %&urkm' %xvmpcnsarion LOVCfabhc. <br />DATF9 _ jar"OLY{ 30, 001_1 <br />SigwdBy: O' -x(--' AlV!q1( <br />Nwne:." fkm & ArEgnt; RulFtn <br />Tide; I_risutr [`Iay% Instructor <br />Ttiephom: 9 �5 <br />WARNING: FAILURE TO SECURE: WORKERS' COMPENSATION COVERAGE IS <br />USLAINTUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMIXAL pEXALTiES <br />AND CIVIL FINES LIP TO ONE HUNDRED THOUSAND DOLLARS (Sl(*,OW). IN <br />ADD1170N TO THE C()STOFCOMPENSATION. DANIA(il-N \S PROVIDED FOR <br />IN SECTION MOF THE LABOR COM INTERES1.:1til) A 1-1 )RNIEY'S FEES, <br />eq.`ell, <br />