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I <br />following declarat; <br />I certify on <br />contract with the S <br />any person in any r <br />California, and agr <br />provisions of Secti <br />provisions. <br />DATE: Septen <br />WARNING: R <br />UNLAWFUL, i <br />AND CIVIL Fn <br />ADDITION TO <br />IN SECTION 3' <br />hereby affirm under penalty of pe�ury, the <br />of Studiofolia that during the tern of my <br />(Organization Name) <br />fthy Dev�etonment Agency, City of Santa Ana, I will noi employ <br />so as to become subject to the workers' compensation 1 aws of <br />if I should become subject to the workers' comoensati n <br />m 377 of the Labor Code, I shall forthwith comply with tho; <br />ber 23, 2019 <br />By: <br />Name: <br />Title: <br />Telephone: <br />James Dinh <br />JRE TO SECURE WORKERS' COMPENSATION COVERAGE <br />IS <br />SHALL SUBJECT AN EMPLOYER TO CRIMINAL PEN <br />TIES <br />UP TO ONE HUNDRED THOUSAND DOLLARS ($lOQ, <br />). IN <br />E COST OF COMPENSATION, DAMAGES AS PROVIDE <br />a FOR <br />OF THE LABOR CODE, INTEREST, AND ATTORNEY'S <br />FEES, <br />& Al"PRO-VED <br />•,,.c xi<:V DivisiO:N <br />12019 <br />M. LAMBERT <br />