Laserfiche WebLink
WORKERS' COMPENSATION DECLARATION <br />I ,O rndW `Hereby affirm under penalty of perjury, the <br />(Name/Title) <br />following declaration <br />I certify on behalf of k 04,y�� � 0 Ajl � that during the term of my <br />contract with the <br />(Organization Name) <br />p" d <br />1�! jLL�✓ r-('ShwY b�ity of Santa Ana, I will not <br />employ any person in any manner so as to become subject to the workers' compensation <br />laws of California, and agree that if I should become subject to the workers' <br />compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply <br />with those provisions. <br />DATE: ' J - ZZ- 741 7J <br />By: 1Nrr m ---x 9v.) �yUO iW <br />Name: <,; M KF 4tyna--,4-eL -- <br />Title: j ti� �Yjv <br />Telephone: ` -31. 150 q 113' <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES <br />AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN <br />ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR <br />IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />