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<br />.' <br /> <br />Feb 12 04 11:40a <br /> <br />T11ac::l <br /> <br />p.4 <br /> <br />Jan 1404 04,OSp <br /> <br />TII"CI <br /> <br />p.1 <br /> <br />~QRIĊ’RS' COMI'F.NSA nON DECLA~JJ~ <br /> <br /> <br />I ¿",EiH ~t',=I'~bY .mrm under penally ofpcljury, the <br />(..""",., O!-'.Nl'e <br />following declaration; <br /> <br />1 ccnifyon behalfof~Fe...<"'o:" ñ("'¡~4uldurillg!helermefmy <br /> <br />to.'."""""""1 <br /> <br />,onlratl with the <br /> <br />,City of8<lnl8 An.. I will nol <br /> <br />employ allY person in any manner so as lC become .ubjecllo!he workers' compensation <br /> <br />law:; ofC....Jifomia. and agree thot if! should becume Kubju"IIO tho work"",' <br /> <br />compensation )rovi.i"n~ of Seclion 3700 ofthe Labor Cede, I ~hall forthwith comply <br /> <br />wl1h those provisions, <br />DATE 01-/</' 2Oð~/- <br /> <br />By ~~.:.,~¿.z> <br />Name: K. :.r.?~FR.lC~ <br />Tide' ð<.UNEe:. <br />Telephone: ,/,0,1- ¿;'.~.t5.~~.?Ý? <br /> <br />WARNING: P AlLURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLA WFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES <br />AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (SIOO,OOO). IN <br />ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROV1DEO FOR <br />TN SECTION 3706 Of THE LABOR CODE, INTEREST, AND ATIORNEY'S FEES. <br /> <br />~~cS* <br />