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WORKER:` COMPENSATION DECLARATION <br />I ✓ ®S �^ v K v� Cd IJ Chereby affirm under penalty of perjury, the <br />(Name/Title) rr <br />following declaration:b- <br />I certify on behalf of L)m c bwa 6,h ro %r -L that during the term of my <br />(Q`gani�ation Name) <br />contract for _�G,l� services with the City of Santa Ana, I <br />will 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. <br />DATE: /0- 2,1• / p <br />By: a " 0;, �,, <br />Name: JOSLtvvY'J-oJe- <br />Title: OW A -a <br />Telephone: 3 L 3 q6 2 963 1 <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 />