Laserfiche WebLink
WORKERS' CO,MP !EA'-S.N LI QN,-qF C LAR Xf 1 Q N ,L_ <br />I hereby affirin under penalty of perjury, the <br />following declaration; "'t, <br />I certify on behalf of that during the term of my <br />—Ad"AA-1 ts <br />(Orimulzatiott Name) <br />contract with the C ty <br />Lo-tily-nu-n-i-ty Ci, 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 became Subject M the %orkers' compensation <br />provisions of'Section 3700 of the Labor Code, I shall forthwith comply with those <br />provisions, <br />DATE: L11i VIZ619 <br />By: <br />Name: <br />Telephone. t cL-,-,2 60 - 7 3o, I <br />WARNINCh FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLANWUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMUNAL PENALTIES <br />AND CIVIL FINES UP TO ONF, HUNDRED THOUSAND DOLLARS ($100,000), IN <br />ADDITION TO THE COST" OF COMPENSATION, DAMAGES AS PROVIDED FOR <br />UNT SECTION 3706 OF WE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, <br />