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CT TV OF SANrA Ax,1 <br />R15k MANAGEMENT s .6rt ew K HuAjAN Rt UXWES <br />— --- - - - ARWWgIng Rik r a* POs M OUnge . <br />WORKERS' COMPENSATION DECLARATION <br />EfIC QaUEf/CaWn@!' hereby affirm under penalty of perjury, the <br />!Humr/)'iJrl� <br />following declaration; <br />I certify orn behalf of Alliance Race riming <br />that during the terns <br />r"��� <br />Of my contract for re8lslxalionlbmirg <br />„ services with the City of Santa Ana, <br />�iYr7/� 1[t4t[4' p`riv�:iedj <br />1 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 tp the <br />viarkers' eompensatian provisions of Se 3700 of the tabor Code, I shall forthwith <br />f.Qmply with the provisions and provide proof of workers' compensation coverage. <br />Date: 8l3/29 <br />Print Frame_ Ei1C Bauer <br />Print Title: <br />owner _ <br />Signature; <br />Telephone: 915-712_3993 <br />WARNING. FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND <br />SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED <br />THG'USAND DOLLARS ($100,0()0)_ IN ADDITIONA1. TO THE COST DF CO PEN ION, S DAMAGF. <br />AS DROVFDED IFOR IN SECTION3706 OF THE LABOR CODE, INTEREST, AND l'.TTrJRNEY S FEES. <br />& APPROVED <br />ir4EMENT DIVISION <br />232021 <br />M. LAMBERT <br />e:at"ff?ArUnwrunc,rlTr�me.", tletr+rtaevds:s�noilsla�9 <br />