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14.2.019-014 <br />f <br />i <br />WORKERS' COMPENSATION DECLARATION✓ <br />V <br />I hereby affirm under penalty of perjury, the <br />(NamelTitle) <br />following declaration: <br />I certify on behalf of LA 61nn`-1 R a, -c rnzc R (SAO that during the term of my <br />(Organization Name) <br />contract with the Community.°_DeVfLoO gent=Agency City of Santa Ana, I will not employ <br />any person in any manner so as to become subject to the workers' compensation laws of <br />California, and agree that if I should become subject to the workers' compensation <br />provisions of Section 3700 of the Labor Code, I shall forthwith comply with those <br />provisions. <br />DATE: <br />vn4,,nn ��1 for <br />lk <br />Eve•.k� <br />By: - Ae,hrn ( L&)(SC1-?J <br />Name: `Ac-nr\L-1 �-fMlj <br />Title: 41-', -c- 1?Y-t�PYie-k'r <br />Telephone: c1-Ar':'i 1 54s — <br />WARNING: FAILURETO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL SUBJECTAN EMPLOYER TO CRIMINAL PENALTIES <br />AND CIVIL FINES UPTO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN <br />ADDITION TO THE COST OF COMPENSATION, DAMAGESAS PROVIDED FOR <br />IN SECTION 37060FTHE LABOR CODE, INTEREST,AND ATTORNEY'S FEES. <br />