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W0R J ItS ( ();L(IT'NSiCION I)l (TAR HON. <br />aveh alfirm under malt Fat pet'nr the <br />tiamv I41c). Y" penalty 'I ":I Y <br />fotlowin- declaration: <br />certify an behalT"cT._....._.{" � ,-_� ealSdrnt durutg the term o'n)y <br />IC"I"111 nn6(o mpanc aNne) <br />contract for Recreation Glasses services Fvith'tho City o(' SFtrna Ann, I will <br />not employ any person in any manner so as to become subject to the workers' <br />eompcan ation laws of California, and aoree that if I should become subject to the <br />workers' compensation provisions oE' Station 3700 of the Labor Code, I shall forthwith <br />comply with those provisions anti provide proof of workers' compensation covmravc, <br />}3y' ..... <br />yp , <br />Name: C1.,.._,...1,,,7-4i_I`�,4G,.,..___..___ <br />WARNING: FAILURES TO SIiCLTE WORKERS' COivlfE?NSATI(,)N COVE'RAGE IS <br />UNLAWFUL, AND SILALI, SUL31Fs'C F AN ENIPLO'YERTO CRIMINAL, P NAI.TIf S <br />AND CIVIL. FINES UP "I'O ONE T-TUNDRE D THOUSAND DOL.I-.ARS (SI00,000). IN <br />Ar)D['I'ION'T`0 I III: C'OS'T' OF COIII'CNSATION, DAMAGES AS PR0V[DLD FOR <br />IN SECTION ,3706 oT' T}IE LABOP CODE, INTEREST. REST. AND AT"IORNh.Y'S L LES. <br />