Laserfiche WebLink
N-2018-183 <br />WORKERS' COMPENSATION DECLARATION <br />C -� AL <br />U 5 CW—IW(l hereby affirm under penalty of perjury, the <br />(Name/Title) <br />following declaration <br />I certify on behalf of <br />Name) <br />that during the term of my <br />not employ any person in any manner so as to become subject to the workers' <br />compensation laws of California, and agree that if I should become subject to the <br />workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith <br />comply with those provisions and provide proof of workers' compensation coverage. <br />DATE: 91-19-4 <br />By: <br />Name: f l R -,7y 13+i0ilti9 <br />Title: ft� ru <br />Telephone: <br />'? 5y- -2 .7 6 - 2 -3 5- � <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 />